add wholesale page to site

We have a site called [login to view URL], and we would like to add a wholesale registration page to it. The page can be similar to what you see below with the following exceptions: [login to view URL] 1) The wholesale page should look like our site and have the same fields except as noted below. 2) There should be a link to "Wholesale" in the index on the left side of our site 3) We require the same fields as the wholesale page above, but we do not need the "i am interested in.." section at all. We do need the comments section however. 4) We need a section below comments entitled "how did you find us?" and space for the wholesaler to type in how he found us. 5) All of the information should be captured once submitted and sent in a clean and professional looking format via email to info@[login to view URL] 6) There must be a security check on the bottom to prevent robots.