1 <HTML><HEAD><TITLE>ISP Signup form</TITLE></HEAD>
2 <BODY BGCOLOR="#e8e8e8"><FONT SIZE=7>ISP Signup form</FONT><BR><BR>
3 <FONT SIZE="+1" COLOR="#ff0000"><%= $error %></FONT>
4 <FORM ACTION="<%= $self_url %>" METHOD=POST>
5 <INPUT TYPE="hidden" NAME="magic" VALUE="process">
6 <INPUT TYPE="hidden" NAME="ref" VALUE="<%= $referral_custnum %>">
7 <INPUT TYPE="hidden" NAME="ss" VALUE="">
9 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
11 <TH ALIGN="right"><font color="#ff0000">*</font>Contact name<BR>(last, first)</TH>
12 <TD COLSPAN=5><INPUT TYPE="text" NAME="last" VALUE="<%= $last %>">,
13 <INPUT TYPE="text" NAME="first" VALUE="<%= $first %>"></TD>
16 <TD ALIGN="right">Company</TD>
17 <TD COLSPAN=5><INPUT TYPE="text" NAME="company" SIZE=70 VALUE="<%= $company %>"></TD>
20 <TH ALIGN="right"><font color="#ff0000">*</font>Address</TH>
21 <TD COLSPAN=5><INPUT TYPE="text" NAME="address1" SIZE=70 VALUE="<%= $address1 %>"></TD>
24 <TD ALIGN="right"> </TD>
25 <TD COLSPAN=5><INPUT TYPE="text" NAME="address2" SIZE=70 VALUE="<%= $address2 %>"></TD>
28 <TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
29 <TD><INPUT TYPE="text" NAME="city" VALUE="<%= $city %>"></TD>
30 <TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
33 ($county_html, $state_html, $country_html) =
34 regionselector( $county, $state, $country );
36 "$county_html $state_html";
39 <TH><font color="#ff0000">*</font>Zip</TH>
40 <TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>"></TD>
43 <TH ALIGN="right"><font color="#ff0000">*</font>Country</TH>
44 <TD><%= $country_html %></TD>
46 <TD ALIGN="right">Day Phone</TD>
47 <TD COLSPAN=5><INPUT TYPE="text" NAME="daytime" VALUE="<%= $daytime %>" SIZE=18></TD>
50 <TD ALIGN="right">Night Phone</TD>
51 <TD COLSPAN=5><INPUT TYPE="text" NAME="night" VALUE="<%= $night %>" SIZE=18></TD>
54 <TD ALIGN="right">Fax</TD>
55 <TD COLSPAN=5><INPUT TYPE="text" NAME="fax" VALUE="<%= $fax %>" SIZE=12></TD>
57 </TABLE><font color="#ff0000">*</font> required fields<BR>
58 <BR>Billing information<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
62 $OUT .= '<INPUT TYPE="checkbox" NAME="invoicing_list_POST" VALUE="POST"';
63 my @invoicing_list = split(', ', $invoicing_list );
65 if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
71 <TR><TD>Email invoice <INPUT TYPE="text" NAME="invoicing_list" VALUE="<%= join(', ', grep { $_ ne 'POST' } split(', ', $invoicing_list ) ) %>">
73 <%= scalar(@payby) > 1 ? '<TR><TD>Billing type</TD></TR>' : '' %>
75 <TABLE BGCOLOR="#c0c0c0" BORDER=1 WIDTH="100%">
80 my $cardselect = '<SELECT NAME="CARD_type"><OPTION></OPTION>';
82 'VISA' => 'VISA card',
83 'MasterCard' => 'MasterCard',
84 'Discover' => 'Discover card',
85 'American Express' => 'American Express card',
87 foreach ( keys %types ) {
88 $selected = $cgi->param('CARD_type') eq $types{$_} ? 'SELECTED' : '';
89 $cardselect .= qq!<OPTION $selected VALUE="$types{$_}">$_</OPTION>!;
91 $cardselect .= '</SELECT>';
94 'CARD' => qq!Credit card<BR><font color="#ff0000">*</font>$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="">!,
95 'DCRD' => qq!Credit card<BR><font color="#ff0000">*</font>$cardselect<INPUT TYPE="text" NAME="DCRD_payinfo" VALUE="" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("DCRD"). qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="DCRD_payname" VALUE="">!,
96 'CHEK' => qq!Electronic check<BR>${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="">!,
97 '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>${r}Bank name <INPUT TYPE="text" NAME="DCHK_payname" VALUE="">!,
98 'LECB' => qq!Phone bill billing<BR>${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="">!,
99 '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">!,
100 '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"),
101 'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="" MAXLENGTH=80>!,
104 my( $account, $aba ) = split('@', $payinfo);
106 'CARD' => qq!Credit card<BR><font color="#ff0000">*</font>$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">!,
107 '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">!,
108 '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">!,
109 '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">!,
110 '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="">!,
111 '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">!,
112 '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", $paydate),
113 'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="$payinfo" MAXLENGTH=80>!,
117 if ( scalar(@payby) == 1) {
118 $OUT .= '<TD VALIGN=TOP>'.
119 qq!<INPUT TYPE="hidden" NAME="payby" VALUE="$_">!.
120 "$paybychecked{$_}</TD>";
122 $OUT .= qq!<TD VALIGN=TOP><INPUT TYPE="radio" NAME="payby" VALUE="$_"!;
124 $OUT .= qq! CHECKED> $paybychecked{$_}</TD>!;
126 $OUT .= qq!> $payby{$_}</TD>!;
133 </TR></TABLE><font color="#ff0000">*</font> required fields for each billing type
134 <BR><BR>First package
135 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
137 <TD COLSPAN=2><SELECT NAME="pkgpart"><OPTION VALUE="">(none)
140 foreach my $package ( @{$packages} ) {
141 $OUT .= '<OPTION VALUE="'. $package->{'pkgpart'}. '"';
142 $OUT .= ' SELECTED' if $pkgpart && $package->{'pkgpart'} == $pkgpart;
143 $OUT .= '>'. $package->{'pkg'};
150 <TD ALIGN="right">Username</TD>
151 <TD><INPUT TYPE="text" NAME="username" VALUE="<%= $username %>"></TD>
154 <TD ALIGN="right">Password</TD>
155 <TD><INPUT TYPE="password" NAME="_password" VALUE="<%= $password %>"></TD>
158 <TD ALIGN="right">Re-enter Password</TD>
159 <TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $password2 %>"></TD>
162 if ( $init_data->{'security_phrase'} ) {
165 <TD ALIGN="right">Security Phrase</TD>
166 <TD><INPUT TYPE="text" NAME="sec_phrase" VALUE="$sec_phrase">
171 $OUT .= '<INPUT TYPE="hidden" NAME="sec_phrase" VALUE="">';
175 if ( scalar(@$pops) ) {
176 $OUT .= '<TR><TD ALIGN="right">Access number</TD><TD>'.
177 popselector($popnum). '</TD></TR>';
179 $OUT .= popselector($popnum);
183 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
184 </FORM></BODY></HTML>