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>
5 <INPUT TYPE="hidden" NAME="magic" VALUE="process">
6 <INPUT TYPE="hidden" NAME="ref" VALUE="<%= $referral_custnum %>">
7 <INPUT TYPE="hidden" NAME="ss" VALUE="">
8 <INPUT TYPE="hidden" NAME="agentnum" VALUE="3">
10 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
12 <TH ALIGN="right"><font color="#ff0000">*</font>Contact name<BR>(last, first)</TH>
13 <TD COLSPAN=5><INPUT TYPE="text" NAME="last" VALUE="<%= $last %>">,
14 <INPUT TYPE="text" NAME="first" VALUE="<%= $first %>"></TD>
17 <TD ALIGN="right">Company</TD>
18 <TD COLSPAN=5><INPUT TYPE="text" NAME="company" SIZE=70 VALUE="<%= $company %>"></TD>
21 <TH ALIGN="right"><font color="#ff0000">*</font>Address</TH>
22 <TD COLSPAN=5><INPUT TYPE="text" NAME="address1" SIZE=70 VALUE="<%= $address1 %>"></TD>
25 <TD ALIGN="right"> </TD>
26 <TD COLSPAN=5><INPUT TYPE="text" NAME="address2" SIZE=70 VALUE="<%= $address2 %>"></TD>
29 <TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
30 <TD><INPUT TYPE="text" NAME="city" VALUE="<%= $city %>"></TD>
31 <TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
32 <TD><SELECT NAME="state" SIZE="1">
35 foreach ( @{$locales} ) {
37 $OUT .= ' SELECTED' if ( $state eq $_->{'state'}
38 && $county eq $_->{'county'}
39 && $country eq $_->{'country'}
41 $OUT .= '>'. $_->{'state'};
42 $OUT .= ' ('. $_->{'county'}. ')' if $_->{'county'};
43 $OUT .= ' / '. $_->{'country'};
48 <TH><font color="#ff0000">*</font>Zip</TH>
49 <TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>"></TD>
52 <TD ALIGN="right">Day Phone</TD>
53 <TD COLSPAN=5><INPUT TYPE="text" NAME="daytime" VALUE="<%= $daytime %>" SIZE=18></TD>
56 <TD ALIGN="right">Night Phone</TD>
57 <TD COLSPAN=5><INPUT TYPE="text" NAME="night" VALUE="<%= $night %>" SIZE=18></TD>
60 <TD ALIGN="right">Fax</TD>
61 <TD COLSPAN=5><INPUT TYPE="text" NAME="fax" VALUE="<%= $fax %>" SIZE=12></TD>
63 </TABLE><font color="#ff0000">*</font> required fields<BR>
68 my %pkgpart2payby = map { $_->{pkgpart} => $_->{payby}[0] } @{$packages};
69 tie my %options, 'Tie::IxHash',
71 map { $_->{pkgpart} => $_->{pkg} } @{$packages}
74 use HTML::Widgets::SelectLayers 0.02;
75 my $widget = new HTML::Widgets::SelectLayers(
77 selected_layer => $pkgpart,
79 form_action => $self_url,
80 form_text => [qw( magic ref ss agentnum
81 last first company address1 address2
82 city zip daytime night fax )],
83 form_select => [qw( state )], #county country
84 layer_callback => sub {
87 <INPUT TYPE="hidden" NAME="pkgpart" VALUE="$layer">
88 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
90 <TH ALIGN="right"><font color="#ff0000">*</font>Username</TH>
91 <TD><INPUT TYPE="text" NAME="username" VALUE="$username"></TD>
94 <TH ALIGN="right"><font color="#ff0000">*</font>Password</TH>
95 <TD><INPUT TYPE="password" NAME="_password" VALUE="$password"></TD>
98 <TH ALIGN="right"><font color="#ff0000">*</font>Re-enter Password</TH>
99 <TD><INPUT TYPE="password" NAME="_password2" VALUE="$password2"></TD>
102 if ( $init_data->{'security_phrase'} ) {
105 <TD ALIGN="right">Security Phrase</TD>
106 <TD><INPUT TYPE="text" NAME="sec_phrase" VALUE="$sec_phrase">
111 $html .= '<INPUT TYPE="hidden" NAME="sec_phrase" VALUE="">';
114 if ( scalar(@$pops) ) {
115 $html .= '<TR><TD ALIGN="right">Access number</TD><TD>'.
116 popselector($popnum). '</TD></TR>';
118 $html .= popselector($popnum);
121 $html .= '</TABLE><font color="#ff0000">*</font> required fields';
123 if ( $pkgpart2payby{$layer} eq 'BILL' ) {
125 <INPUT TYPE="hidden" NAME="payby" VALUE="BILL">
126 <INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
127 <INPUT TYPE="hidden" NAME="BILL_payinfo" VALUE="">
128 <INPUT TYPE="hidden" NAME="BILL_month" VALUE="12">
129 <INPUT TYPE="hidden" NAME="BILL_year" VALUE="2037">
130 <INPUT TYPE="hidden" NAME="BILL_payname" VALUE="">
131 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
133 } elsif ( $pkgpart2payby{$layer} eq 'CARD' ) {
134 my $postal_checked = '';
135 my @invoicing_list = split(', ', $invoicing_list );
136 $postal_checked = 'CHECKED'
137 if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
139 $invoicing_list= join(', ', grep { $_ ne 'POST' } @invoicing_list );
141 my $expselect = expselect("CARD", $paydate);
143 my $cardselect = '<SELECT NAME="CARD_type"><OPTION></OPTION>';
145 'VISA' => 'VISA card',
146 'MasterCard' => 'MasterCard',
147 'Discover' => 'Discover card',
148 'American Express' => 'American Express card',
150 foreach ( keys %types ) {
152 $cgi->param('CARD_type') eq $types{$_} ? 'SELECTED' : '';
154 qq!<OPTION $selected VALUE="$types{$_}">$_</OPTION>!;
156 $cardselect .= '</SELECT>';
159 <INPUT TYPE="hidden" NAME="payby" VALUE="CARD">
160 <BR><BR>Billing information
161 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
162 <INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
164 <TD ALIGN="right">Email statement to </TD>
165 <TD><INPUT TYPE="text" NAME="invoicing_list" VALUE="$invoicing_list"></TD>
168 <TH ALIGN="right"><font color="#ff0000">*</font>Credit card type</TH>
172 <TH ALIGN="right"><font color="#ff0000">*</font>Card number</TH>
173 <TD><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="$payinfo" MAXLENGTH=19></TD>
176 <TH ALIGN="right"><font color="#ff0000">*</font>*</font>Exp</TH>
180 <TH ALIGN="right"><font color="#ff0000">*</font>Name on card</TH>
181 <TD><INPUT TYPE="text" NAME="CARD_payname" VALUE="$payname"></TD>
184 <font color="#ff0000">*</font> required fields
185 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
189 <BR>Please select a package.<BR>