<FORM NAME="OneTrueForm" ACTION="<%= $self_url %>" METHOD=POST onSubmit="document.OneTrueForm.signup.disabled=true">
<INPUT TYPE="hidden" NAME="session" VALUE="<%= $session_id %>">
<INPUT TYPE="hidden" NAME="action" VALUE="process_signup">
+<INPUT TYPE="hidden" NAME="agentnum" VALUE="<%= $agentnum %>">
<INPUT TYPE="hidden" NAME="referral_custnum" VALUE="<%= $referral_custnum %>">
<INPUT TYPE="hidden" NAME="ss" VALUE="">
<input type="hidden" name="payby">
<TR>
<TH ALIGN="right"><font color="#ff0000">*</font>City</TH>
<TD><INPUT TYPE="text" NAME="city" VALUE="<%= $city %>"></TD>
- <TH ALIGN="right"><font color="#ff0000">*</font>State/Country</TH>
- <TD>
<%=
($county_html, $state_html, $country_html) =
regionselector( {
locales => \@cust_main_county,
} );
- "$county_html $state_html";
%>
+ <TH ALIGN="right"><font color="#ff0000">*</font>
+ <%= ($county_html =~ /SELECT/) ? 'County/State' : 'State' %></TH>
+ <TD>
+ <%= "$county_html $state_html"; %>
</TD>
<TH><font color="#ff0000">*</font>Zip</TH>
<TD><INPUT TYPE="text" NAME="zip" SIZE=10 VALUE="<%= $zip %>"></TD>