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>
66 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
68 <TH ALIGN="right"><font color="#ff0000">*</font>Username</TH>
69 <TD><INPUT TYPE="text" NAME="username" VALUE="<%= $username %>"></TD>
72 <TH ALIGN="right"><font color="#ff0000">*</font>Password</TH>
73 <TD><INPUT TYPE="password" NAME="_password" VALUE="<%= $password %>"></TD>
76 <TH ALIGN="right"><font color="#ff0000">*</font>Re-enter Password</TH>
77 <TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $password2 %>"></TD>
80 <%= if ( $init_data->{'security_phrase'} ) {
83 <TD ALIGN="right">Security Phrase</TD>
84 <TD><INPUT TYPE="text" NAME="sec_phrase" VALUE="$sec_phrase">
89 '<INPUT TYPE="hidden" NAME="sec_phrase" VALUE="">';
93 <%= if ( scalar(@$pops) ) {
94 '<TR><TD ALIGN="right">Access number</TD><TD>'.
95 popselector($popnum). '</TD></TR>';
101 </TABLE><font color="#ff0000">*</font> required fields
103 <BR><BR>First package
106 my %pkgpart2payby = map { $_->{pkgpart} => $_->{payby}[0] } @{$packages};
107 tie my %options, 'Tie::IxHash',
109 map { $_->{pkgpart} => $_->{pkg} } @{$packages}
112 use HTML::Widgets::SelectLayers 0.02;
113 my $widget = new HTML::Widgets::SelectLayers(
114 options => \%options,
115 selected_layer => $pkgpart,
116 form_name => 'dummy',
117 form_action => $self_url,
118 form_text => [qw( magic ref ss agentnum
119 last first company address1 address2
120 city zip daytime night fax )],
121 form_select => [qw( state )], #county country
122 layer_callback => sub {
124 my $html = qq( <INPUT TYPE="hidden" NAME="pkgpart" VALUE="$layer">);
126 if ( $pkgpart2payby{$layer} eq 'BILL' ) {
128 <INPUT TYPE="hidden" NAME="payby" VALUE="BILL">
129 <INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
130 <INPUT TYPE="hidden" NAME="BILL_payinfo" VALUE="">
131 <INPUT TYPE="hidden" NAME="BILL_month" VALUE="12">
132 <INPUT TYPE="hidden" NAME="BILL_year" VALUE="2037">
133 <INPUT TYPE="hidden" NAME="BILL_payname" VALUE="">
134 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
136 } elsif ( $pkgpart2payby{$layer} eq 'CARD' ) {
137 my $postal_checked = '';
138 my @invoicing_list = split(', ', $invoicing_list );
139 $postal_checked = 'CHECKED'
140 if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
142 $invoicing_list= join(', ', grep { $_ ne 'POST' } @invoicing_list );
144 my $expselect = expselect("CARD", $paydate);
146 my $cardselect = '<SELECT NAME="CARD_type"><OPTION></OPTION>';
148 'VISA' => 'VISA card',
149 'MasterCard' => 'MasterCard',
150 'Discover' => 'Discover card',
151 'American Express' => 'American Express card',
153 foreach ( keys %types ) {
155 $cgi->param('CARD_type') eq $types{$_} ? 'SELECTED' : '';
157 qq!<OPTION $selected VALUE="$types{$_}">$_</OPTION>!;
159 $cardselect .= '</SELECT>';
162 <INPUT TYPE="hidden" NAME="payby" VALUE="CARD">
163 <BR><BR>Billing information
164 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0>
165 <INPUT TYPE="hidden" NAME="invoicing_list_POST" VALUE="">
167 <TD ALIGN="right">Email statement to </TD>
168 <TD><INPUT TYPE="text" NAME="invoicing_list" VALUE="$invoicing_list"></TD>
171 <TH ALIGN="right"><font color="#ff0000">*</font>Credit card type</TH>
175 <TH ALIGN="right"><font color="#ff0000">*</font>Card number</TH>
176 <TD><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="$payinfo" MAXLENGTH=19></TD>
179 <TH ALIGN="right"><font color="#ff0000">*</font>*</font>Exp</TH>
183 <TH ALIGN="right"><font color="#ff0000">*</font>Name on card</TH>
184 <TD><INPUT TYPE="text" NAME="CARD_payname" VALUE="$payname"></TD>
187 <font color="#ff0000">*</font> required fields
188 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
192 <BR>Please select a package.<BR>