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+<HTML><HEAD><TITLE>ISP Signup form</TITLE></HEAD>
+<BODY BGCOLOR="#e8e8e8"><FONT SIZE=7>ISP Signup form</FONT><BR><BR>
+<FONT SIZE="+1" COLOR="#ff0000"><%= $error %></FONT>
+<FORM NAME="dummy">
+<INPUT TYPE="hidden" NAME="magic" VALUE="process">
+<INPUT TYPE="hidden" NAME="ref" VALUE="<%= $referral_custnum %>">
+<INPUT TYPE="hidden" NAME="ss" VALUE="">
+<INPUT TYPE="hidden" NAME="agentnum" VALUE="3">
+Contact Information
+<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Contact name<BR>(last, first)</TH>
+ <TD COLSPAN=5><INPUT TYPE="text" NAME="last" VALUE="<%= $last %>">,
+ <INPUT TYPE="text" NAME="first" VALUE="<%= $first %>"></TD>
+</TR>
+<TR>
+ <TD ALIGN="right">Company</TD>
+ <TD COLSPAN=5><INPUT TYPE="text" NAME="company" SIZE=70 VALUE="<%= $company %>"></TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Address</TH>
+ <TD COLSPAN=5><INPUT TYPE="text" NAME="address1" SIZE=70 VALUE="<%= $address1 %>"></TD>
+</TR>
+<TR>
+ <TD ALIGN="right">&nbsp;</TD>
+ <TD COLSPAN=5><INPUT TYPE="text" NAME="address2" SIZE=70 VALUE="<%= $address2 %>"></TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
+ <TD><INPUT TYPE="text" NAME="city" VALUE="<%= $city %>"></TD>
+ <TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
+ <TD><SELECT NAME="state" SIZE="1">
+
+ <%=
+ foreach ( @{$locales} ) {
+ my $value = $_->{'state'};
+ $value .= ' ('. $_->{'county'}. ')' if $_->{'county'};
+ $value .= ' / '. $_->{'country'};
+
+ $OUT .= qq(<OPTION VALUE="$value");
+ $OUT .= ' SELECTED' if ( $state eq $_->{'state'}
+ && $county eq $_->{'county'}
+ && $country eq $_->{'country'}
+ );
+ $OUT .= ">$value</OPTION>";
+ }
+ %>
+
+ </SELECT></TD>
+ <TH><font color="#ff0000">*</font>Zip</TH>
+ <TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>"></TD>
+</TR>
+<TR>
+ <TD ALIGN="right">Day Phone</TD>
+ <TD COLSPAN=5><INPUT TYPE="text" NAME="daytime" VALUE="<%= $daytime %>" SIZE=18></TD>
+</TR>
+<TR>
+ <TD ALIGN="right">Night Phone</TD>
+ <TD COLSPAN=5><INPUT TYPE="text" NAME="night" VALUE="<%= $night %>" SIZE=18></TD>
+</TR>
+<TR>
+ <TD ALIGN="right">Fax</TD>
+ <TD COLSPAN=5><INPUT TYPE="text" NAME="fax" VALUE="<%= $fax %>" SIZE=12></TD>
+</TR>
+</TABLE><font color="#ff0000">*</font> required fields<BR>
+
+<BR><BR>
+<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Username</TH>
+ <TD><INPUT TYPE="text" NAME="username" VALUE="<%= $username %>"></TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Password</TH>
+ <TD><INPUT TYPE="password" NAME="_password" VALUE="<%= $password %>"></TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Re-enter Password</TH>
+ <TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $password2 %>"></TD>
+</TR>
+
+<%= if ( $init_data->{'security_phrase'} ) {
+ <<ENDOUT;
+<TR>
+ <TD ALIGN="right">Security Phrase</TD>
+ <TD><INPUT TYPE="text" NAME="sec_phrase" VALUE="$sec_phrase">
+ </TD>
+</TR>
+ENDOUT
+ } else {
+ '<INPUT TYPE="hidden" NAME="sec_phrase" VALUE="">';
+ }
+%>
+
+<%= if ( scalar(@$pops) ) {
+ '<TR><TD ALIGN="right">Access number</TD><TD>'.
+ popselector($popnum). '</TD></TR>';
+ } else {
+ popselector($popnum);
+ }
+%>
+
+</TABLE><font color="#ff0000">*</font> required fields
+
+<BR><BR>First package
+
+ <%= use Tie::IxHash;
+ my %pkgpart2payby = map { $_->{pkgpart} => $_->{payby}[0] } @{$packages};
+ tie my %options, 'Tie::IxHash',
+ '' => '(none)',
+ map { $_->{pkgpart} => $_->{pkg} }
+ sort { $a->{recur} <=> $b->{recur} }
+ @{$packages}
+ ;
+
+ use HTML::Widgets::SelectLayers 0.02;
+ my @form_text = qw( magic ref ss agentnum
+ last first company address1 address2
+ city zip daytime night fax
+ username _password _password2 sec_phrase );
+ my @form_select = qw( state ); #county country
+ if ( scalar(@$pops) == 0 or scalar(@$pops) == 1 ) {
+ push @form_text, 'popnum',
+ } else {
+ push @form_select, 'popnum',
+ }
+ my $widget = new HTML::Widgets::SelectLayers(
+ options => \%options,
+ selected_layer => $pkgpart,
+ form_name => 'dummy',
+ form_action => $self_url,
+ form_text => \@form_text,
+ form_select => \@form_select,
+ layer_callback => sub {
+ my $layer = shift;
+ my $html = qq( <INPUT TYPE="hidden" NAME="pkgpart" VALUE="$layer">);
+
+ if ( $pkgpart2payby{$layer} eq 'BILL' ) {
+ $html .= <<ENDOUT;
+<INPUT TYPE="hidden" NAME="payby" VALUE="BILL">
+<INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
+<INPUT TYPE="hidden" NAME="BILL_payinfo" VALUE="">
+<INPUT TYPE="hidden" NAME="BILL_month" VALUE="12">
+<INPUT TYPE="hidden" NAME="BILL_year" VALUE="2037">
+<INPUT TYPE="hidden" NAME="BILL_payname" VALUE="">
+<BR><BR><INPUT TYPE="submit" VALUE="Signup">
+ENDOUT
+ } elsif ( $pkgpart2payby{$layer} eq 'CARD' ) {
+ my $postal_checked = '';
+ my @invoicing_list = split(', ', $invoicing_list );
+ $postal_checked = 'CHECKED'
+ if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
+
+ $invoicing_list= join(', ', grep { $_ ne 'POST' } @invoicing_list );
+
+ my $expselect = expselect("CARD", $paydate);
+
+ my $cardselect = '<SELECT NAME="CARD_type"><OPTION></OPTION>';
+ my %types = (
+ 'VISA' => 'VISA card',
+ 'MasterCard' => 'MasterCard',
+ 'Discover' => 'Discover card',
+ 'American Express' => 'American Express card',
+ );
+ foreach ( keys %types ) {
+ $selected =
+ $cgi->param('CARD_type') eq $types{$_} ? 'SELECTED' : '';
+ $cardselect .=
+ qq!<OPTION $selected VALUE="$types{$_}">$_</OPTION>!;
+ }
+ $cardselect .= '</SELECT>';
+
+ $html .= <<ENDOUT;
+<INPUT TYPE="hidden" NAME="payby" VALUE="CARD">
+<BR><BR>Billing information
+<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
+<INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
+<TR>
+ <TD ALIGN="right">Email statement to </TD>
+ <TD><INPUT TYPE="text" NAME="invoicing_list" VALUE="$invoicing_list"></TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Credit card type</TH>
+ <TD>$cardselect</TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Card number</TH>
+ <TD><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="$payinfo" MAXLENGTH=19></TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>*</font>Exp</TH>
+ <TD>$expselect</TD>
+</TR>
+<TR>
+ <TH ALIGN="right"><font color="#ff0000">*</font>Name on card</TH>
+ <TD><INPUT TYPE="text" NAME="CARD_payname" VALUE="$payname"></TD>
+</TR>
+</TABLE>
+<font color="#ff0000">*</font> required fields
+<BR><BR><INPUT TYPE="submit" VALUE="Signup">
+ENDOUT
+ } else {
+ $html = <<ENDOUT;
+<BR>Please select a package.<BR>
+ENDOUT
+
+ }
+
+ $html;
+
+ },
+ );
+
+ $widget->html;
+
+
+ %>
+</BODY></HTML>