Custom registration form - Magento 1.6.2

Hello fellow freelancers! One of my clients is running Magento, and we've got this extension: [login to view URL] Our current website has 2 stores (website views, technically speaking) - one for retail, one for wholesale. This website currently has a single registration form (the default Magento one), but we need another registration page that displays a custom registration form for resellers. Here's the info needed on the custom registration form (* = required) (TITLE) WHOLESALE CUSTOMER SIGN-UP: (CHECKBOXES) *I am a: [ ] Retailer/Reseller [ ] Distributor [ ] Health Practitioner ------------------------------ (TITLE) MINIMUM ORDER REQUIREMENT: (CHECKBOX) *[ ] I understand there is a minimum amount of $320 order on all bulk orders ------------------------------ (TEXT FIELDS) - *Company Name - Company Website - *Contact Name - *Email Address - *Phone - Fax - *Street Address - *City - *State (drop down list of US states) - *Zip ------------------------------ (TITLE) RESELLER REGISTRATION: (TEXT FIELD) - *Resale License # (The "label" of this field is chained to the "State" drop-down menu) ===============> *THIS IS WHERE IT GETS A LITTLE BIT TRICKY! <================ Different states have different names for the Resale License # (while some states don't require it at all). Depending on which state is selected, the text for "Resale License #" may change to one of these: - Sales and Use Tax # - Transaction Privilege Tax # - Sellers Permit # - Resale Certificate # - Sales Tax License # - Sales Tax Resale Certificate # - Reseller Permit # - not required (field would disappear or gray out) This is where it gets a little bit easier... For our purposes, the Magento admin panel (or "attribute") will always be called "Reseller #". The dynamic labels in this registration form are NOT tied into the Magento database. The actual form "field id" will always be the same, regardless of what the label says. The idea here is simply to make it easier for resellers to fill out the necessary info to avoid confusion. In Magento, signing up with the reseller form will only register them as a regular customer -- just like the standard Magento form. If they are approved as a reseller, then the admin will simply switch their group from "customer" to "wholesale". This new registration page will be published under the "wholesale view" so that we can configure Magento to require admin approval before they have permission to access the wholesale section. (We will use a customer activation extension for this.) Once the form has been submitted successfully, the form should re-direct to a thank you page. (I'll create that page) <-------------------------- END OF PROJECT ---------------------------> Let me know if you have any questions. Thanks!