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<HTML><HEAD><TITLE>ISP Signup form</TITLE></HEAD>
<BODY BGCOLOR="#e8e8e8" onUnload="myclose()">
<script language="JavaScript"><!--
var mywindow = -1;
function myopen(filename,windowname,properties) {
myclose();
mywindow = window.open(filename,windowname,properties);
}
function myclose() {
if ( mywindow != -1 )
mywindow.close();
mywindow = -1
}
//--></script>
<FONT SIZE=7>ISP Signup form</FONT><BR><BR>
<FONT SIZE="+1" COLOR="#ff0000"><%= $error %></FONT>
<FORM NAME="OneTrueForm" ACTION="<%= $self_url %>" METHOD=POST onSubmit="document.OneTrueForm.signup.disabled=true">
<INPUT TYPE="hidden" NAME="magic" VALUE="process">
<INPUT TYPE="hidden" NAME="ref" VALUE="<%= $referral_custnum %>">
<INPUT TYPE="hidden" NAME="ss" VALUE="">
Where did you hear about our service? <SELECT NAME="refnum">
<%=
$OUT .= '<OPTION VALUE="">' unless $refnum;
foreach my $part_referral ( @{$init_data->{'part_referral'}} ) {
$OUT .= '<OPTION VALUE="'. $part_referral->{'refnum'}. '"';
$OUT .= ' SELECTED' if $part_referral->{'refnum'} eq $refnum;
$OUT .= '>'. $part_referral->{'referral'};
}
%>
</SELECT><BR><BR>
Billing Address (where credit card statement is sent)
<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>Exact name on card<BR>(last, first)</TH>
<TD COLSPAN=5><INPUT TYPE="text" NAME="last" VALUE="<%= $last %>" onChange="changed(this)">,
<INPUT TYPE="text" NAME="first" VALUE="<%= $first %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right">Company</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="company" SIZE=70 VALUE="<%= $company %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>Address</TH>
<TD COLSPAN=5><INPUT TYPE="text" NAME="address1" SIZE=70 VALUE="<%= $address1 %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right"> </TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="address2" SIZE=70 VALUE="<%= $address2 %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
<TD><INPUT TYPE="text" NAME="city" VALUE="<%= $city %>" onChange="changed(this)"></TD>
<TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
<TD>
<%=
($county_html, $state_html, $country_html) =
regionselector( $county, $state, $country, '', 'changed(this)' );
"$county_html $state_html";
%>
</TD>
<TH><font color="#ff0000">*</font>Zip</TH>
<TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>Country</TH>
<TD><%= $country_html %></TD>
<TR>
<TD ALIGN="right">Day Phone</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="daytime" VALUE="<%= $daytime %>" SIZE=18 onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right">Night Phone</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="night" VALUE="<%= $night %>" SIZE=18 onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right">Fax</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="fax" VALUE="<%= $fax %>" SIZE=12 onChange="changed(this)"></TD>
</TR>
</TABLE>
<SCRIPT>
function changed(what) {
what.form.same.checked = false;
}
function samechanged(what) {
if ( what.checked ) {
<%= foreach (qw(
last first company address1 address2 city zip daytime night fax
)) {
$OUT .= "what.form.ship_$_.value = what.form.$_.value;\n";
}
%>
what.form.ship_country.selectedIndex = what.form.country.selectedIndex;
ship_country_changed(what.form.ship_country);
what.form.ship_state.selectedIndex = what.form.state.selectedIndex;
ship_state_changed(what.form.ship_state);
what.form.ship_county.selectedIndex = what.form.county.selectedIndex;
}
}
</SCRIPT>
<BR><BR>
Service Address
(<INPUT TYPE="checkbox" NAME="same" VALUE="Y" onClick="samechanged(this)" <%= $same eq 'Y' ? 'CHECKED' : '' %>>same as billing address)<BR>
<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="ship_last" VALUE="<%= $ship_last %>" onChange="changed(this)">,
<INPUT TYPE="text" NAME="ship_first" VALUE="<%= $ship_first %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right">Company</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="ship_company" SIZE=70 VALUE="<%= $ship_company %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>Address</TH>
<TD COLSPAN=5><INPUT TYPE="text" NAME="ship_address1" SIZE=70 VALUE="<%= $ship_address1 %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right"> </TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="ship_address2" SIZE=70 VALUE="<%= $ship_address2 %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
<TD><INPUT TYPE="text" NAME="ship_city" VALUE="<%= $ship_city %>" onChange="changed(this)"></TD>
<TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
<TD>
<%=
($ship_county_html, $ship_state_html, $ship_country_html) =
regionselector( $ship_county,
$ship_state,
$ship_country,
'ship_',
'changed(this)',
);
"$ship_county_html $ship_state_html";
%>
</TD>
<TH><font color="#ff0000">*</font>Zip</TH>
<TD><INPUT TYPE="text" NAME="ship_zip" SIZE=10 VALUE="<%= $ship_zip %>" onChange="changed(this)"></TD>
</TR>
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>Country</TH>
<TD><%= $ship_country_html %></TD>
<TR>
<TD ALIGN="right">Day Phone</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="ship_daytime" VALUE="<%= $ship_daytime %>" SIZE=18 onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right">Night Phone</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="ship_night" VALUE="<%= $ship_night %>" SIZE=18 onChange="changed(this)"></TD>
</TR>
<TR>
<TD ALIGN="right">Fax</TD>
<TD COLSPAN=5><INPUT TYPE="text" NAME="ship_fax" VALUE="<%= $ship_fax %>" SIZE=12 onChange="changed(this)"></TD>
</TR>
</TABLE>
<font color="#ff0000">*</font> required fields<BR>
<BR>Billing information<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
<TR><TD>
<%=
$OUT .= '<INPUT TYPE="checkbox" NAME="invoicing_list_POST" VALUE="POST"';
my @invoicing_list = split(', ', $invoicing_list );
$OUT .= ' CHECKED'
if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
$OUT .= '>';
%>
Postal mail invoice
</TD></TR>
<TR><TD>Email invoice <INPUT TYPE="text" NAME="invoicing_list" VALUE="<%= join(', ', grep { $_ ne 'POST' } split(', ', $invoicing_list ) ) %>">
</TD></TR>
<%= scalar(@payby) > 1 ? '<TR><TD>Billing type</TD></TR>' : '' %>
</TABLE>
<TABLE BGCOLOR="#c0c0c0" BORDER=1 WIDTH="100%">
<TR>
<%=
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>!;
}
$cardselect .= '</SELECT>';
my %payby = (
'CARD' => qq!Credit card<BR><font color="#ff0000">*</font>$cardselect<INPUT TYPE="text" NAME="CARD_payinfo" VALUE="" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("CARD"), #. qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="CARD_payname" VALUE="">!,
'DCRD' => qq!Credit card<BR><font color="#ff0000">*</font>$cardselect<INPUT TYPE="text" NAME="DCRD_payinfo" VALUE="" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("DCRD"), #. qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="DCRD_payname" VALUE="">!,
'CHEK' => qq!Electronic check<BR>${r}Account number <INPUT TYPE="text" NAME="CHEK_payinfo1" VALUE="" MAXLENGTH=10><BR>${r}ABA/Routing code <INPUT TYPE="text" NAME="CHEK_payinfo2" VALUE="" SIZE=10 MAXLENGTH=9><INPUT TYPE="hidden" NAME="CHEK_month" VALUE="12"><INPUT TYPE="hidden" NAME="CHEK_year" VALUE="2037"><BR>${r}Bank name <INPUT TYPE="text" NAME="CHEK_payname" VALUE="">!,
'DCHK' => qq!Electronic check<BR>${r}Account number <INPUT TYPE="text" NAME="DCHK_payinfo1" VALUE="" MAXLENGTH=10><BR>${r}ABA/Routing code <INPUT TYPE="text" NAME="DCHK_payinfo2" VALUE="" SIZE=10 MAXLENGTH=9><INPUT TYPE="hidden" NAME="DCHK_month" VALUE="12"><INPUT TYPE="hidden" NAME="DCHK_year" VALUE="2037"><BR>${r}Bank name <INPUT TYPE="text" NAME="DCHK_payname" VALUE="">!,
'LECB' => qq!Phone bill billing<BR>${r}Phone number <INPUT TYPE="text" BANE="LECB_payinfo" VALUE="" MAXLENGTH=15 SIZE=16><INPUT TYPE="hidden" NAME="LECB_month" VALUE="12"><INPUT TYPE="hidden" NAME="LECB_year" VALUE="2037"><INPUT TYPE="hidden" NAME="LECB_payname" VALUE="">!,
'BILL' => qq!Billing<BR>P.O. <INPUT TYPE="text" NAME="BILL_payinfo" VALUE=""><BR><font color="#ff0000">*</font>Exp !. expselect("BILL", "12-2037"). qq!<BR><font color="#ff0000">*</font>Attention<BR><INPUT TYPE="text" NAME="BILL_payname" VALUE="Accounts Payable">!,
'COMP' => qq!Complimentary<BR><font color="#ff0000">*</font>Approved by<INPUT TYPE="text" NAME="COMP_payinfo" VALUE=""><BR><font color="#ff0000">*</font>Exp !. expselect("COMP"),
'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="" MAXLENGTH=80>!,
);
if ( $init_data->{'cvv_enabled'} ) {
foreach my $payby ( grep { exists $payby{$_} } qw(CARD DCRD) ) { #1.4/1.5
$payby{$payby} .= qq!<BR>CVV2 (<A HREF="javascript:myopen('cvv2.html','cvv2','toolbar=no,location=no,directories=no,status=no,menubar=no,scrollbars=no,resizable=yes,copyhistory=no,width=480,height=288')">help</A>) <INPUT TYPE="text" NAME=${payby}_paycvv VALUE="" SIZE=4 MAXLENGTH=4>!;
}
}
my( $account, $aba ) = split('@', $payinfo);
my %paybychecked = (
'CARD' => qq!Credit card<BR><font color="#ff0000">*</font>$cardselect<INPUT TYPE="text" NAME="CARD_payinfo" VALUE="$payinfo" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("CARD", $paydate), #. qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="CARD_payname" VALUE="$payname">!,
'DCRD' => qq!Credit card<BR><font color="#ff0000">*</font>$cardselect<INPUT TYPE="text" NAME="DCRD_payinfo" VALUE="$payinfo" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("DCRD", $paydate), #. qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="DCRD_payname" VALUE="$payname">!,
'CHEK' => qq!Electronic check<BR>${r}Account number <INPUT TYPE="text" NAME="CHEK_payinfo1" VALUE="$account" MAXLENGTH=10><BR>${r}ABA/Routing code <INPUT TYPE="text" NAME="CHEK_payinfo2" VALUE="$aba" SIZE=10 MAXLENGTH=9><INPUT TYPE="hidden" NAME="CHEK_month" VALUE="12"><INPUT TYPE="hidden" NAME="CHEK_year" VALUE="2037"><BR>${r}Bank name <INPUT TYPE="text" NAME="CHEK_payname" VALUE="$payname">!,
'DCHK' => qq!Electronic check<BR>${r}Account number <INPUT TYPE="text" NAME="DCHK_payinfo1" VALUE="$account" MAXLENGTH=10><BR>${r}ABA/Routing code <INPUT TYPE="text" NAME="DCHK_payinfo2" VALUE="$aba" SIZE=10 MAXLENGTH=9><INPUT TYPE="hidden" NAME="DCHK_month" VALUE="12"><INPUT TYPE="hidden" NAME="DCHK_year" VALUE="2037"><BR>${r}Bank name <INPUT TYPE="text" NAME="DCHK_payname" VALUE="$payname">!,
'LECB' => qq!Phone bill billing<BR>${r}Phone number <INPUT TYPE="text" BANE="LECB_payinfo" VALUE="$payinfo" MAXLENGTH=15 SIZE=16><INPUT TYPE="hidden" NAME="LECB_month" VALUE="12"><INPUT TYPE="hidden" NAME="LECB_year" VALUE="2037"><INPUT TYPE="hidden" NAME="LECB_payname" VALUE="">!,
'BILL' => qq!Billing<BR>P.O. <INPUT TYPE="text" NAME="BILL_payinfo" VALUE="$payinfo"><BR><font color="#ff0000">*</font>Exp !. expselect("BILL", $paydate). qq!<BR><font color="#ff0000">*</font>Attention<BR><INPUT TYPE="text" NAME="BILL_payname" VALUE="$payname">!,
'COMP' => qq!Complimentary<BR><font color="#ff0000">*</font>Approved by<INPUT TYPE="text" NAME="COMP_payinfo" VALUE="$payinfo"><BR><font color="#ff0000">*</font>Exp !. expselect("COMP", $paydate),
'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="$payinfo" MAXLENGTH=80>!,
);
if ( $init_data->{'cvv_enabled'} ) {
foreach my $payby ( grep { exists $payby{$_} } qw(CARD DCRD) ) { #1.4/1.5
$paybychecked{$payby} .= qq!<BR>CVV2 (<A HREF="javascript:myopen('cvv2.html','cvv2','toolbar=no,location=no,directories=no,status=no,menubar=no,scrollbars=no,resizable=yes,copyhistory=no,width=480,height=288')">help</A>) <INPUT TYPE="text" NAME=${payby}_paycvv VALUE="$paycvv" SIZE=4 MAXLENGTH=4>!;
}
}
for (@payby) {
if ( scalar(@payby) == 1) {
$OUT .= '<TD VALIGN=TOP>'.
qq!<INPUT TYPE="hidden" NAME="payby" VALUE="$_">!.
"$paybychecked{$_}</TD>";
} else {
$OUT .= qq!<TD VALIGN=TOP><INPUT TYPE="radio" NAME="payby" VALUE="$_"!;
if ($payby eq $_) {
$OUT .= qq! CHECKED> $paybychecked{$_}</TD>!;
} else {
$OUT .= qq!> $payby{$_}</TD>!;
}
}
}
%>
</TR></TABLE><font color="#ff0000">*</font> required fields for each billing type
<BR><BR>First package
<INPUT TYPE="hidden" NAME="promo_code" VALUE="<%= $cgi->param('promo_code') %>">
<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
<TR>
<TD COLSPAN=2><SELECT NAME="pkgpart">
<%=
$OUT .= '<OPTION VALUE="">(none)' unless scalar(@$packages) == 1;
foreach my $package ( @{$packages} ) {
$OUT .= '<OPTION VALUE="'. $package->{'pkgpart'}. '"';
$OUT .= ' SELECTED'
if ( $pkgpart && $package->{'pkgpart'} == $pkgpart )
|| scalar(@$packages) == 1;
$OUT .= '>'. $package->{'pkg'};
}
%>
</SELECT></TD>
</TR>
<TR>
<TD ALIGN="right">Username</TD>
<TD><INPUT TYPE="text" NAME="username" VALUE="<%= $username %>"></TD>
</TR>
<TR>
<TD ALIGN="right">Password</TD>
<TD><INPUT TYPE="password" NAME="_password" VALUE="<%= $password %>"></TD>
</TR>
<TR>
<TD ALIGN="right">Re-enter Password</TD>
<TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $password2 %>"></TD>
</TR>
<%=
if ( $init_data->{'security_phrase'} ) {
$OUT .= <<ENDOUT;
<TR>
<TD ALIGN="right">Security Phrase</TD>
<TD><INPUT TYPE="text" NAME="sec_phrase" VALUE="$sec_phrase">
</TD>
</TR>
ENDOUT
} else {
$OUT .= '<INPUT TYPE="hidden" NAME="sec_phrase" VALUE="">';
}
%>
<%=
if ( scalar(@$pops) ) {
$OUT .= '<TR><TD ALIGN="right">Access number</TD><TD>'.
popselector($popnum). '</TD></TR>';
} else {
$OUT .= popselector($popnum);
}
%>
</TABLE>
<BR><BR><INPUT TYPE="submit" NAME="signup" VALUE="Signup">
</FORM></BODY></HTML>
|
