HTML + PHP: Fix a table based page

Please, see the PDF attached. I have a html code and I need it displayed without unformatting.I have 2 fields (they are table cells) I need to be displayed without unformatting of the page. The project consist: 1) Fix the code between to not distort the page - they are textfields. Both text on fields are used to the email will be sent by a php code. 2) Center the webpage on screen. 3) Fix the [login to view URL] to load another page after email sent. Javascript not allowed. CSS only if necessary, however this specific page was made using tables and images so I don't wanna a new website using CSS. Access to the FTP will be provided to the hired freelancer. Happy bidding!