ISP Signup form
<%= $error %>
Where did you hear about our service?
<%= $OUT .= '
' unless $refnum; foreach my $part_referral ( @{$init_data->{'part_referral'}} ) { $OUT .= '
{'refnum'} eq $refnum; $OUT .= '>'. $part_referral->{'referral'}; } %>
Billing Address (where credit card statement is sent)
*
Exact name on card
(last, first)
,
Company
*
Address
*
City
*
State/Country
<%= ($county_html, $state_html, $country_html) = regionselector( $county, $state, $country, '', 'changed(this)' ); "$county_html $state_html"; %>
*
Zip
*
Country
<%= $country_html %>
Day Phone
Night Phone
Fax
Service Address (
>same as billing address)
*
Contact name
(last, first)
,
Company
*
Address
*
City
*
State/Country
<%= ($ship_county_html, $ship_state_html, $ship_country_html) = regionselector( $ship_county, $ship_state, $ship_country, 'ship_', 'changed(this)', ); "$ship_county_html $ship_state_html"; %>
*
Zip
*
Country
<%= $ship_country_html %>
Day Phone
Night Phone
Fax
*
required fields
Billing information
<%= $OUT .= '
Postal mail invoice
Email invoice
<%= scalar(@payby) > 1 ? '
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
!, '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 ( $init_data->{'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 ( $init_data->{'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) { $OUT .= '
'. qq!
!. "$paybychecked{$_}
"; } else { $OUT .= qq!
$paybychecked{$_}
!; } else { $OUT .= qq!> $payby{$_}!; } } } %>
*
required fields for each billing type
First package
<%= $OUT .= '
(none)' unless scalar(@$packages) == 1; foreach my $package ( @{$packages} ) { $OUT .= '
{'pkgpart'} == $pkgpart ) || scalar(@$packages) == 1; $OUT .= '>'. $package->{'pkg'}; } %>
Username
Password
Re-enter Password
<%= if ( $init_data->{'security_phrase'} ) { $OUT .= <
Security Phrase
ENDOUT } else { $OUT .= '
'; } %> <%= if ( scalar(@$pops) ) { $OUT .= '
Access number
'. popselector($popnum). '
'; } else { $OUT .= popselector($popnum); } %>