<%= $agent || 'ISP' %> Signup form

<%= $error %>

Where did you hear about our service? <%= $OUT .= '' unless $refnum; foreach my $part_referral ( @part_referral ) { $OUT .= '{'refnum'} eq $refnum; $OUT .= '>'. $part_referral->{'referral'}; } %>

Contact Information

*Contact name (last, first)	,
Company
*Address
*City		*State/Country	<%= ($county_html, $state_html, $country_html) = regionselector( { selected_county => $county, selected_state => $state, selected_country => $country, default_state => $statedefault, default_country => $countrydefault, locales => \@cust_main_county, } ); "$county_html $state_html"; %>	*Zip
*Country	<%= $country_html %>
Day Phone
Night Phone
Fax

* required fields

Billing information <%= scalar(@payby) > 1 ? '' : '' %>

<%= $OUT .= ' Postal mail invoice

Email invoice

Billing type

<%= my $cardselect = ''; my %types = ( 'VISA' => 'VISA card', 'MasterCard' => 'MasterCard', 'Discover' => 'Discover card', 'American Express' => 'American Express card', ); foreach ( keys %types ) { $selected = $CARD_type eq $types{$_} ? 'SELECTED' : ''; $cardselect .= qq!$_!; } $cardselect .= ''; my %payby = ( 'CARD' => qq!Credit card
*$cardselect
*Exp !. expselect("CARD"). qq!
*Name on card
!, 'DCRD' => qq!Credit card
*$cardselect
*Exp !. expselect("DCRD"). qq!
*Name on card
!, 'CHEK' => qq!Electronic check
${r}Account number
${r}ABA/Routing code
${r}Bank name !, 'DCHK' => qq!Electronic check
${r}Account number
${r}ABA/Routing code
${r}Bank name !, 'LECB' => qq!Phone bill billing
${r}Phone number !, 'BILL' => qq!Billing
P.O.
*Exp !. expselect("BILL", "12-2037"). qq!
*Attention
!, 'COMP' => qq!Complimentary
*Approved by
*Exp !. expselect("COMP"), 'PREPAY' => qq!Prepaid card
*!, ); if ( $cvv_enabled ) { foreach my $payby ( grep { exists $payby{$_} } qw(CARD DCRD) ) { #1.4/1.5 $payby{$payby} .= qq!
CVV2 (help) !; } } my( $account, $aba ) = split('@', $payinfo); my %paybychecked = ( 'CARD' => qq!Credit card
*$cardselect
*Exp !. expselect("CARD", $paydate). qq!
*Name on card
!, 'DCRD' => qq!Credit card
*$cardselect
*Exp !. expselect("DCRD", $paydate). qq!
*Name on card
!, 'CHEK' => qq!Electronic check
${r}Account number
${r}ABA/Routing code
${r}Bank name !, 'DCHK' => qq!Electronic check
${r}Account number
${r}ABA/Routing code
${r}Bank name !, 'LECB' => qq!Phone bill billing
${r}Phone number !, 'BILL' => qq!Billing
P.O.
*Exp !. expselect("BILL", $paydate). qq!
*Attention
!, 'COMP' => qq!Complimentary
*Approved by
*Exp !. expselect("COMP", $paydate), 'PREPAY' => qq!Prepaid card
*!, ); if ( $cvv_enabled ) { foreach my $payby ( grep { exists $payby{$_} } qw(CARD DCRD) ) { #1.4/1.5 $paybychecked{$payby} .= qq!
CVV2 (help) !; } } for (@payby) { if ( scalar(@payby) == 1) { $OUT .= '"; } else { $OUT .= qq!!; } else { $OUT .= qq!> $payby{$_}!; } } } %>

'. qq!!. "$paybychecked{$_}

$paybychecked{$_}

* required fields for each billing type

First package <%= if ( $security_phrase ) { $OUT .= < ENDOUT } else { $OUT .= ''; } %> <%= if ( @svc_acct_pop ) { $OUT .= ''; } else { $OUT .= popselector(popnum=>$popnum, pops=>\@svc_acct_pop); } %>

(none) <%= foreach my $part_pkg ( @part_pkg ) { $OUT .= '{'pkgpart'} == $pkgpart; $OUT .= '>'. $part_pkg->{'pkg'}; } %>
Username
Password
Re-enter Password
Security Phrase
Access number	'. popselector( 'popnum' => $popnum, 'pops' => \@svc_acct_pop, 'init_popstate' => $init_popstate, 'popac' => $popac, 'acstate' => $acstate, ). '