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} ) {
36 my $value = $_->{'state'};
37 $value .= ' ('. $_->{'county'}. ')' if $_->{'county'};
38 $value .= ' / '. $_->{'country'};
40 $OUT .= qq(<OPTION VALUE="$value");
41 $OUT .= ' SELECTED' if ( $state eq $_->{'state'}
42 && $county eq $_->{'county'}
43 && $country eq $_->{'country'}
45 $OUT .= ">$value</OPTION>";
50 <TH><font color="#ff0000">*</font>Zip</TH>
51 <TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>"></TD>
54 <TD ALIGN="right">Day Phone</TD>
55 <TD COLSPAN=5><INPUT TYPE="text" NAME="daytime" VALUE="<%= $daytime %>" SIZE=18></TD>
58 <TD ALIGN="right">Night Phone</TD>
59 <TD COLSPAN=5><INPUT TYPE="text" NAME="night" VALUE="<%= $night %>" SIZE=18></TD>
62 <TD ALIGN="right">Fax</TD>
63 <TD COLSPAN=5><INPUT TYPE="text" NAME="fax" VALUE="<%= $fax %>" SIZE=12></TD>
65 </TABLE><font color="#ff0000">*</font> required fields<BR>
68 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
70 <TH ALIGN="right"><font color="#ff0000">*</font>Username</TH>
71 <TD><INPUT TYPE="text" NAME="username" VALUE="<%= $username %>"></TD>
74 <TH ALIGN="right"><font color="#ff0000">*</font>Password</TH>
75 <TD><INPUT TYPE="password" NAME="_password" VALUE="<%= $password %>"></TD>
78 <TH ALIGN="right"><font color="#ff0000">*</font>Re-enter Password</TH>
79 <TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $password2 %>"></TD>
82 <%= if ( $init_data->{'security_phrase'} ) {
85 <TD ALIGN="right">Security Phrase</TD>
86 <TD><INPUT TYPE="text" NAME="sec_phrase" VALUE="$sec_phrase">
91 '<INPUT TYPE="hidden" NAME="sec_phrase" VALUE="">';
95 <%= if ( scalar(@$pops) ) {
96 '<TR><TD ALIGN="right">Access number</TD><TD>'.
97 popselector($popnum). '</TD></TR>';
103 </TABLE><font color="#ff0000">*</font> required fields
105 <BR><BR>First package
108 my %pkgpart2payby = map { $_->{pkgpart} => $_->{payby}[0] } @{$packages};
109 tie my %options, 'Tie::IxHash',
111 map { $_->{pkgpart} => $_->{pkg} } @{$packages}
114 use HTML::Widgets::SelectLayers 0.02;
115 my $widget = new HTML::Widgets::SelectLayers(
116 options => \%options,
117 selected_layer => $pkgpart,
118 form_name => 'dummy',
119 form_action => $self_url,
120 form_text => [qw( magic ref ss agentnum
121 last first company address1 address2
122 city zip daytime night fax
123 username password sec_phrase )],
124 form_select => [qw( state popnum )], #county country
125 layer_callback => sub {
127 my $html = qq( <INPUT TYPE="hidden" NAME="pkgpart" VALUE="$layer">);
129 if ( $pkgpart2payby{$layer} eq 'BILL' ) {
131 <INPUT TYPE="hidden" NAME="payby" VALUE="BILL">
132 <INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
133 <INPUT TYPE="hidden" NAME="BILL_payinfo" VALUE="">
134 <INPUT TYPE="hidden" NAME="BILL_month" VALUE="12">
135 <INPUT TYPE="hidden" NAME="BILL_year" VALUE="2037">
136 <INPUT TYPE="hidden" NAME="BILL_payname" VALUE="">
137 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
139 } elsif ( $pkgpart2payby{$layer} eq 'CARD' ) {
140 my $postal_checked = '';
141 my @invoicing_list = split(', ', $invoicing_list );
142 $postal_checked = 'CHECKED'
143 if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
145 $invoicing_list= join(', ', grep { $_ ne 'POST' } @invoicing_list );
147 my $expselect = expselect("CARD", $paydate);
149 my $cardselect = '<SELECT NAME="CARD_type"><OPTION></OPTION>';
151 'VISA' => 'VISA card',
152 'MasterCard' => 'MasterCard',
153 'Discover' => 'Discover card',
154 'American Express' => 'American Express card',
156 foreach ( keys %types ) {
158 $cgi->param('CARD_type') eq $types{$_} ? 'SELECTED' : '';
160 qq!<OPTION $selected VALUE="$types{$_}">$_</OPTION>!;
162 $cardselect .= '</SELECT>';
165 <INPUT TYPE="hidden" NAME="payby" VALUE="CARD">
166 <BR><BR>Billing information
167 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
168 <INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
170 <TD ALIGN="right">Email statement to </TD>
171 <TD><INPUT TYPE="text" NAME="invoicing_list" VALUE="$invoicing_list"></TD>
174 <TH ALIGN="right"><font color="#ff0000">*</font>Credit card type</TH>
178 <TH ALIGN="right"><font color="#ff0000">*</font>Card number</TH>
179 <TD><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="$payinfo" MAXLENGTH=19></TD>
182 <TH ALIGN="right"><font color="#ff0000">*</font>*</font>Exp</TH>
186 <TH ALIGN="right"><font color="#ff0000">*</font>Name on card</TH>
187 <TD><INPUT TYPE="text" NAME="CARD_payname" VALUE="$payname"></TD>
190 <font color="#ff0000">*</font> required fields
191 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
195 <BR>Please select a package.<BR>