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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 ACTION="<%= $self_url %>" METHOD=POST>
<INPUT TYPE="hidden" NAME="magic" VALUE="process">
<INPUT TYPE="hidden" NAME="ref" VALUE="<%= $referral_custnum %>">
<INPUT TYPE="hidden" NAME="ss" VALUE="">
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"> </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} ) {
$OUT .= '<OPTION';
$OUT .= ' SELECTED' if ( $state eq $_->{'state'}
&& $county eq $_->{'county'}
&& $country eq $_->{'country'}
);
$OUT .= '>'. $_->{'state'};
$OUT .= ' ('. $_->{'county'}. ')' if $_->{'county'};
$OUT .= ' / '. $_->{'country'};
}
%>
</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>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(', ', $invoicing_list ) ) %>">
</TD></TR>
<TR><TD>Billing type</TD></TR></TABLE>
<TABLE BGCOLOR="#c0c0c0" BORDER=1 WIDTH="100%">
<TR>
<%=
my %payby = (
'CARD' => qq!Credit card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("CARD"). qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="CARD_payname" VALUE="">!,
'BILL' => qq!Billing<BR>P.O. <INPUT TYPE="text" NAME="BILL_payinfo" VALUE=""><BR><font color="#ff0000">*</font>Exp !. expselect("BILL", "12-2037"). qq!<BR><font color="#ff0000">*</font>Attention<BR><INPUT TYPE="text" NAME="BILL_payname" VALUE="Accounts Payable">!,
'COMP' => qq!Complimentary<BR><font color="#ff0000">*</font>Approved by<INPUT TYPE="text" NAME="COMP_payinfo" VALUE=""><BR><font color="#ff0000">*</font>Exp !. expselect("COMP"),
'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="" MAXLENGTH=80>!,
);
my %paybychecked = (
'CARD' => qq!Credit card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="$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">!,
'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>!,
);
for (@payby) {
$OUT .= qq!<TD VALIGN=TOP><INPUT TYPE="radio" NAME="payby" VALUE="$_"!;
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
<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
<TR>
<TD COLSPAN=2><SELECT NAME="pkgpart"><OPTION VALUE="">(none)
<%=
foreach my $package ( @{$packages} ) {
$OUT .= '<OPTION VALUE="'. $package->{'pkgpart'}. '"';
$OUT .= ' SELECTED' if $pkgpart && $package->{'pkgpart'} == $pkgpart;
$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="text" NAME="_password" VALUE="<%= $password %>">
(blank to generate)</TD>
</TR>
<TR>
<TD ALIGN="right">Access number</TD>
<TD><%= popselector($popnum) %></TD>
</TR>
</TABLE>
<BR><BR><INPUT TYPE="submit" VALUE="Signup">
</FORM></BODY></HTML>
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