--- /dev/null
+<% ntable("#cccccc") %>
+
+% if ( $opt{'phonenum'} ) {
+
+ <INPUT TYPE="hidden" NAME="loop_type" VALUE="">
+ <INPUT TYPE="hidden" NAME="phonenum" VALUE="<% $opt{'phonenum'} %>">
+
+ <TR>
+ <TD ALIGN="right">Loop Type</TD>
+ <TD BGCOLOR="#eeeeee">Line-share</TD>
+ </TR>
+
+ <TR>
+ <TD ALIGN="right">Phone Number</TD>
+ <TD BGCOLOR="#eeeeee"><% $opt{'phonenum'} %></TD>
+ </TR>
+
+% } else {
+
+ <INPUT TYPE="hidden" NAME="loop_type" VALUE="0">
+ <INPUT TYPE="hidden" NAME="phonenum" VALUE="">
+
+ <TR>
+ <TD ALIGN="right">Loop Type</TD>
+ <TD BGCOLOR="#eeeeee">Standalone</TD>
+ </TR>
+
+% }
+
+<TR>
+ <TD ALIGN="right">PPPoE password</TD>
+ <TD>
+ <INPUT TYPE = "text"
+ NAME = "password"
+ VALUE = "<% $opt{'password'} %>"
+ >
+ </TD>
+</TR>
+
+<TR>
+ <TD ALIGN="right">ISP Changing?</TD>
+ <TD>
+ <INPUT TYPE = "checkbox"
+ NAME = "isp_chg"
+ VALUE = "Y"
+ <% $opt{'isp_chg'} eq 'Y' ? 'CHECKED' : '' %>
+ >
+ </TD>
+</TR>
+
+<TR>
+ <TD ALIGN="right">Current or Previous ISP</TD>
+ <TD>
+ <INPUT TYPE = "text"
+ NAME = "isp_prev"
+ VALUE = "<% $opt{'isp_prev'} %>"
+ >
+ </TD>
+</TR>
+
+<INPUT TYPE="hidden" NAME="vendor_qual_id" VALUE="<% $opt{'vendor_qual_id'} %>">
+<TR>
+ <TD ALIGN="right">Vendor Qualification ID</TD>
+ <TD BGCOLOR="#eeeeee"><% $opt{'vendor_qual_id'} %></TD>
+</TR>
+
+</TABLE>
+
+<%init>
+
+my %opt = @_;
+
+#my $conf = new FS::Conf;
+
+</%init>