-<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="password" NAME="_password" VALUE="<%= $password %>">
- (blank to generate)</TD>
-</TR>
-<TR>
- <TD ALIGN="right">Re-enter Password</TD>
- <TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $password2 %>">
- </TD>
-</TR>
-<TR>
- <TD ALIGN="right">Access number</TD>
- <TD><%= popselector($popnum) %></TD>
-</TR>
-</TABLE>
-<BR><BR><INPUT TYPE="submit" VALUE="Signup">
-</FORM></BODY></HTML>