ISP Signup form

<%= $error %>

Contact Information

*Contact name (last, first)	,
Company
*Address
*City		*State/Country	<%= foreach ( @{$locales} ) { $OUT .= '{'state'} && $county eq $_->{'county'} && $country eq $_->{'country'} ); $OUT .= '>'. $_->{'state'}; $OUT .= ' ('. $_->{'county'}. ')' if $_->{'county'}; $OUT .= ' / '. $_->{'country'}; } %>	*Zip
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 = $cgi->param('CARD_type') eq $types{$_} ? 'SELECTED' : ''; $cardselect .= qq!$_!; } $cardselect .= ''; my %payby = ( 'CARD' => qq!Credit card
*$cardselect
*Exp !. expselect("CARD"). qq!
*Name on card
!, 'BILL' => qq!Billing
P.O.
*Exp !. expselect("BILL", "12-2037"). qq!
*Attention
!, 'COMP' => qq!Complimentary
*Approved by
*Exp !. expselect("COMP"), 'PREPAY' => qq!Prepaid card
*!, ); my %paybychecked = ( 'CARD' => qq!Credit card
*$cardselect
*Exp !. expselect("CARD", $paydate). qq!
*Name on card
!, 'BILL' => qq!Billing
P.O.
*Exp !. expselect("BILL", $paydate). qq!
*Attention
!, 'COMP' => qq!Complimentary
*Approved by
*Exp !. expselect("COMP", $paydate), 'PREPAY' => qq!Prepaid card
*!, ); 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 ( $init_data->{'security_phrase'} ) { $OUT .= < ENDOUT } else { $OUT .= ''; } %>

(none) <%= foreach my $package ( @{$packages} ) { $OUT .= '{'pkgpart'} == $pkgpart; $OUT .= '>'. $package->{'pkg'}; } %>
Username
Password	(blank to generate)
Re-enter Password
Security Phrase
Access number	<%= popselector($popnum) %>