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>
4 <FORM ACTION="<%= $self_url %>" METHOD=POST>
5 <INPUT TYPE="hidden" NAME="magic" VALUE="process">
6 <INPUT TYPE="hidden" NAME="ref" VALUE="<%= $referral_custnum %>">
7 <INPUT TYPE="hidden" NAME="ss" VALUE="">
9 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
11 <TH ALIGN="right"><font color="#ff0000">*</font>Contact name<BR>(last, first)</TH>
12 <TD COLSPAN=5><INPUT TYPE="text" NAME="last" VALUE="<%= $last %>">,
13 <INPUT TYPE="text" NAME="first" VALUE="<%= $first %>"></TD>
16 <TD ALIGN="right">Company</TD>
17 <TD COLSPAN=5><INPUT TYPE="text" NAME="company" SIZE=70 VALUE="<%= $company %>"></TD>
20 <TH ALIGN="right"><font color="#ff0000">*</font>Address</TH>
21 <TD COLSPAN=5><INPUT TYPE="text" NAME="address1" SIZE=70 VALUE="<%= $address1 %>"></TD>
24 <TD ALIGN="right"> </TD>
25 <TD COLSPAN=5><INPUT TYPE="text" NAME="address2" SIZE=70 VALUE="<%= $address2 %>"></TD>
28 <TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
29 <TD><INPUT TYPE="text" NAME="city" VALUE="<%= $city %>"></TD>
30 <TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
31 <TD><SELECT NAME="state" SIZE="1">
34 foreach ( @{$locales} ) {
36 $OUT .= ' SELECTED' if ( $state eq $_->{'state'}
37 && $county eq $_->{'county'}
38 && $country eq $_->{'country'}
40 $OUT .= '>'. $_->{'state'};
41 $OUT .= ' ('. $_->{'county'}. ')' if $_->{'county'};
42 $OUT .= ' / '. $_->{'country'};
47 <TH><font color="#ff0000">*</font>Zip</TH>
48 <TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>"></TD>
51 <TD ALIGN="right">Day Phone</TD>
52 <TD COLSPAN=5><INPUT TYPE="text" NAME="daytime" VALUE="<%= $daytime %>" SIZE=18></TD>
55 <TD ALIGN="right">Night Phone</TD>
56 <TD COLSPAN=5><INPUT TYPE="text" NAME="night" VALUE="<%= $night %>" SIZE=18></TD>
59 <TD ALIGN="right">Fax</TD>
60 <TD COLSPAN=5><INPUT TYPE="text" NAME="fax" VALUE="<%= $fax %>" SIZE=12></TD>
62 </TABLE><font color="#ff0000">*</font> required fields<BR>
63 <BR>Billing information<TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
67 $OUT .= '<INPUT TYPE="checkbox" NAME="invoicing_list_POST" VALUE="POST"';
68 my @invoicing_list = split(', ', $invoicing_list );
70 if ! @invoicing_list || grep { $_ eq 'POST' } @invoicing_list;
76 <TR><TD>Email invoice <INPUT TYPE="text" NAME="invoicing_list" VALUE="<%= join(', ', grep { $_ ne 'POST' } split(', ', $invoicing_list ) ) %>">
78 <TR><TD>Billing type</TD></TR></TABLE>
79 <TABLE BGCOLOR="#c0c0c0" BORDER=1 WIDTH="100%">
84 'CARD' => qq!Credit card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="" MAXLENGTH=19><BR><font color="#ff0000">*</font>Exp !. expselect("CARD"). qq!<BR><font color="#ff0000">*</font>Name on card<BR><INPUT TYPE="text" NAME="CARD_payname" VALUE="">!,
85 'BILL' => qq!Billing<BR>P.O. <INPUT TYPE="text" NAME="BILL_payinfo" VALUE=""><BR><font color="#ff0000">*</font>Exp !. expselect("BILL", "12-2037"). qq!<BR><font color="#ff0000">*</font>Attention<BR><INPUT TYPE="text" NAME="BILL_payname" VALUE="Accounts Payable">!,
86 'COMP' => qq!Complimentary<BR><font color="#ff0000">*</font>Approved by<INPUT TYPE="text" NAME="COMP_payinfo" VALUE=""><BR><font color="#ff0000">*</font>Exp !. expselect("COMP"),
87 'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="" MAXLENGTH=80>!,
91 'CARD' => qq!Credit card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="CARD_payinfo" VALUE="$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">!,
92 '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">!,
93 '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", $paydate),
94 'PREPAY' => qq!Prepaid card<BR><font color="#ff0000">*</font><INPUT TYPE="text" NAME="PREPAY_payinfo" VALUE="$payinfo" MAXLENGTH=80>!,
98 $OUT .= qq!<TD VALIGN=TOP><INPUT TYPE="radio" NAME="payby" VALUE="$_"!;
100 $OUT .= qq! CHECKED> $paybychecked{$_}</TD>!;
102 $OUT .= qq!> $payby{$_}</TD>!;
107 </TR></TABLE><font color="#ff0000">*</font> required fields for each billing type
108 <BR><BR>First package
109 <TABLE BGCOLOR="#c0c0c0" BORDER=0 CELLSPACING=0 WIDTH="100%">
111 <TD COLSPAN=2><SELECT NAME="pkgpart"><OPTION VALUE="">(none)
114 foreach my $package ( @{$packages} ) {
115 $OUT .= '<OPTION VALUE="'. $package->{'pkgpart'}. '"';
116 $OUT .= ' SELECTED' if $pkgpart && $package->{'pkgpart'} == $pkgpart;
117 $OUT .= '>'. $package->{'pkg'};
124 <TD ALIGN="right">Username</TD>
125 <TD><INPUT TYPE="text" NAME="username" VALUE="<%= $username %>"></TD>
128 <TD ALIGN="right">Password</TD>
129 <TD><INPUT TYPE="text" NAME="_password" VALUE="<%= $password %>">
130 (blank to generate)</TD>
133 <TD ALIGN="right">Re-enter Password</TD>
134 <TD><INPUT TYPE="password" NAME="_password2" VALUE="<%= $password2 %>">
138 <TD ALIGN="right">Access number</TD>
139 <TD><%= popselector($popnum) %></TD>
142 <BR><BR><INPUT TYPE="submit" VALUE="Signup">
143 </FORM></BODY></HTML>