- my $r = qq!<font color="#ff0000">*</font>!;
- my $self_url = $cgi->self_url;
-
- print $cgi->header( '-expires' => 'now' ), <<END;
-<HTML><HEAD><TITLE>ISP Signup form</TITLE></HEAD>
-<BODY BGCOLOR="#e8e8e8"><FONT SIZE=7>ISP Signup form</FONT><BR><BR>
-END
-
- print qq!<FONT SIZE="+1" COLOR="#ff0000">Error: $error</FONT>! if $error;
-
- print <<END;
-<FORM ACTION="$self_url" METHOD=POST>
-<INPUT TYPE="hidden" NAME="magic" VALUE="process">
-Contact Information
-<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
-<TR>
- <TH ALIGN="right">${r}Contact name<BR>(last, first)</TH>
- <TD COLSPAN=3><INPUT TYPE="text" NAME="last" VALUE="$last">,
- <INPUT TYPE="text" NAME="first" VALUE="$first"></TD>
- <TD ALIGN="right">SS#</TD>
- <TD><INPUT TYPE="text" NAME="ss" SIZE=11 VALUE="$ss"></TD>
-</TR>
-<TR>
- <TD ALIGN="right">Company</TD>
- <TD COLSPAN=5><INPUT TYPE="text" NAME="company" SIZE=70 VALUE="$company"></TD>
-</TR>
-<TR>
- <TH ALIGN="right">${r}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">${r}City</TH>
- <TD><INPUT TYPE="text" NAME="city" VALUE="$city"></TD>
- <TH ALIGN="right">${r}State/Country</TH>
- <TD><SELECT NAME="state" SIZE="1">
-END
-
- foreach ( @{$locales} ) {
- print "<OPTION";
- print " SELECTED" if ( $state eq $_->{'state'}
- && $county eq $_->{'county'}
- && $country eq $_->{'country'}
- );
- print ">", $_->{'state'};
- print " (",$_->{'county'},")" if $_->{'county'};
- print " / ", $_->{'country'};
- }
-
- print <<END;
- </SELECT></TD>
- <TH>${r}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>$r required fields<BR>
-<BR>Billing information<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
-<TR><TD>
-END
-
- print qq!<INPUT TYPE="checkbox" NAME="invoicing_list_POST" VALUE="POST"!;
- my @invoicing_list = split(', ', $invoicing_list );
- print ' CHECKED'
- if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
- print '>Postal mail invoice</TD></TR><TR><TD>Email invoice ',
- qq!<INPUT TYPE="text" NAME="invoicing_list" VALUE="!,
- join(', ', grep { $_ ne 'POST' } @invoicing_list ),
- qq!"></TD></TR>!;
-
- print <<END;
-<TR><TD>Billing type</TD></TR></TABLE>
-<TABLE BGCOLOR="#c0c0c0" BORDER=1 WIDTH="100%">
-<TR>
-END