1 <HTML><HEAD><TITLE><%= $agent || 'ISP' %> Signup form</TITLE></HEAD>
2 <BODY BGCOLOR="#e8e8e8" onUnload="myclose()">
3 <script language="JavaScript"><!--
5 function myopen(filename,windowname,properties) {
7 mywindow = window.open(filename,windowname,properties);
15 <FONT SIZE=7><%= $agent || 'ISP' %> Signup form</FONT><BR><BR>
16 <FONT SIZE="+1" COLOR="#ff0000"><%= $error %></FONT>
17 <FORM ACTION="<%= $selfurl %>" METHOD=POST>
18 <INPUT TYPE="hidden" NAME="session" VALUE="<%= $session_id %>">
19 <INPUT TYPE="hidden" NAME="action" VALUE="process_signup">
20 <INPUT TYPE="hidden" NAME="ref" VALUE="<%= $referral_custnum %>">
21 <INPUT TYPE="hidden" NAME="ss" VALUE="">
22 Where did you hear about our service? <SELECT NAME="refnum">
24 $OUT .= '<OPTION VALUE="">' unless $refnum;
25 foreach my $part_referral ( @part_referral ) {
26 $OUT .= '<OPTION VALUE="'. $part_referral->{'refnum'}. '"';
27 $OUT .= ' SELECTED' if $part_referral->{'refnum'} eq $refnum;
28 $OUT .= '>'. $part_referral->{'referral'};
33 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
35 <TH ALIGN="right"><font color="#ff0000">*</font>Contact name<BR>(last, first)</TH>
36 <TD COLSPAN=5><INPUT TYPE="text" NAME="last" VALUE="<%= $last %>">,
37 <INPUT TYPE="text" NAME="first" VALUE="<%= $first %>"></TD>
40 <TD ALIGN="right">Company</TD>
41 <TD COLSPAN=5><INPUT TYPE="text" NAME="company" SIZE=70 VALUE="<%= $company %>"></TD>
44 <TH ALIGN="right"><font color="#ff0000">*</font>Address</TH>
45 <TD COLSPAN=5><INPUT TYPE="text" NAME="address1" SIZE=70 VALUE="<%= $address1 %>"></TD>
48 <TD ALIGN="right"> </TD>
49 <TD COLSPAN=5><INPUT TYPE="text" NAME="address2" SIZE=70 VALUE="<%= $address2 %>"></TD>
52 <TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
53 <TD><INPUT TYPE="text" NAME="city" VALUE="<%= $city %>"></TD>
54 <TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
57 ($county_html, $state_html, $country_html) =
59 selected_county => $county,
60 selected_state => $state,
61 selected_country => $country,
62 default_state => $statedefault,
63 default_country => $countrydefault,
64 locales => \@cust_main_county,
67 "$county_html $state_html";
70 <TH><font color="#ff0000">*</font>Zip</TH>
71 <TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>"></TD>
74 <TH ALIGN="right"><font color="#ff0000">*</font>Country</TH>
75 <TD><%= $country_html %></TD>
77 <TD ALIGN="right">Day Phone</TD>
78 <TD COLSPAN=5><INPUT TYPE="text" NAME="daytime" VALUE="<%= $daytime %>" SIZE=18></TD>
81 <TD ALIGN="right">Night Phone</TD>
82 <TD COLSPAN=5><INPUT TYPE="text" NAME="night" VALUE="<%= $night %>" SIZE=18></TD>
85 <TD ALIGN="right">Fax</TD>
86 <TD COLSPAN=5><INPUT TYPE="text" NAME="fax" VALUE="<%= $fax %>" SIZE=12></TD>
88 </TABLE><font color="#ff0000">*</font> required fields<BR>
89 <BR>Billing information<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
93 $OUT .= '<INPUT TYPE="checkbox" NAME="invoicing_list_POST" VALUE="POST"';
94 my @invoicing_list = split(', ', $invoicing_list );
96 if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
102 <TR><TD>Email invoice <INPUT TYPE="text" NAME="invoicing_list" VALUE="<%= join(', ', grep { $_ ne 'POST' } split(', ', $invoicing_list ) ) %>">
104 <%= scalar(@payby) > 1 ? '<TR><TD>Billing type</TD></TR>' : '' %>
106 <TABLE BGCOLOR="#c0c0c0" BORDER=1 WIDTH="100%">
111 my $cardselect = '<SELECT NAME="CARD_type"><OPTION></OPTION>';
113 'VISA' => 'VISA card',
114 'MasterCard' => 'MasterCard',
115 'Discover' => 'Discover card',
116 'American Express' => 'American Express card',
118 foreach ( keys %types ) {
119 $selected = $CARD_type eq $types{$_} ? 'SELECTED' : '';
120 $cardselect .= qq!<OPTION $selected VALUE="$types{$_}">$_</OPTION>!;
122 $cardselect .= '</SELECT>';
125 'CARD' => qq!Credit card<BR><font color="#ff0000">*</font>$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="">!,
126 'DCRD' => qq!Credit card<BR><font color="#ff0000">*</font>$cardselect<INPUT TYPE="text" NAME="DCRD_payinfo" VALUE="" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("DCRD"). qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="DCRD_payname" VALUE="">!,
127 'CHEK' => qq!Electronic check<BR>${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="">!,
128 '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>${r}Bank name <INPUT TYPE="text" NAME="DCHK_payname" VALUE="">!,
129 'LECB' => qq!Phone bill billing<BR>${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="">!,
130 '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">!,
131 '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"),
132 'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="" MAXLENGTH=80>!,
135 if ( $cvv_enabled ) {
136 foreach my $payby ( grep { exists $payby{$_} } qw(CARD DCRD) ) { #1.4/1.5
137 $payby{$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>!;
141 my( $account, $aba ) = split('@', $payinfo);
143 'CARD' => qq!Credit card<BR><font color="#ff0000">*</font>$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">!,
144 '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">!,
145 '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">!,
146 '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">!,
147 '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="">!,
148 '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">!,
149 '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", $paydate),
150 'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="$payinfo" MAXLENGTH=80>!,
153 if ( $cvv_enabled ) {
154 foreach my $payby ( grep { exists $payby{$_} } qw(CARD DCRD) ) { #1.4/1.5
155 $paybychecked{$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>!;
160 if ( scalar(@payby) == 1) {
161 $OUT .= '<TD VALIGN=TOP>'.
162 qq!<INPUT TYPE="hidden" NAME="payby" VALUE="$_">!.
163 "$paybychecked{$_}</TD>";
165 $OUT .= qq!<TD VALIGN=TOP><INPUT TYPE="radio" NAME="payby" VALUE="$_"!;
167 $OUT .= qq! CHECKED> $paybychecked{$_}</TD>!;
169 $OUT .= qq!> $payby{$_}</TD>!;
176 </TR></TABLE><font color="#ff0000">*</font> required fields for each billing type
177 <BR><BR>First package
178 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
180 <TD COLSPAN=2><SELECT NAME="pkgpart"><OPTION VALUE="">(none)
183 foreach my $part_pkg ( @part_pkg ) {
184 $OUT .= '<OPTION VALUE="'. $part_pkg->{'pkgpart'}. '"';
185 $OUT .= ' SELECTED' if $pkgpart && $part_pkg->{'pkgpart'} == $pkgpart;
186 $OUT .= '>'. $part_pkg->{'pkg'};
193 <TD ALIGN="right">Username</TD>
194 <TD><INPUT TYPE="text" NAME="username" VALUE="<%= $username %>"></TD>
197 <TD ALIGN="right">Password</TD>
198 <TD><INPUT TYPE="password" NAME="_password" VALUE="<%= $_password %>"></TD>
201 <TD ALIGN="right">Re-enter Password</TD>
202 <TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $_password2 %>"></TD>
205 if ( $security_phrase ) {
208 <TD ALIGN="right">Security Phrase</TD>
209 <TD><INPUT TYPE="text" NAME="sec_phrase" VALUE="$sec_phrase">
214 $OUT .= '<INPUT TYPE="hidden" NAME="sec_phrase" VALUE="">';
218 if ( @svc_acct_pop ) {
219 $OUT .= '<TR><TD ALIGN="right">Access number</TD><TD>'.
220 popselector( 'popnum' => $popnum,
221 'pops' => \@svc_acct_pop,
222 'init_popstate' => $init_popstate,
224 'acstate' => $acstate,
228 $OUT .= popselector(popnum=>$popnum, pops=>\@svc_acct_pop);
232 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
233 </FORM></BODY></HTML>