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'}; } %>

Contact Information

*Contact name (last, first)	,
Company
*Address
*City		*State/Country	<%= ($county_html, $state_html, $country_html) = regionselector( $county, $state, $country ); "$county_html $state_html"; %>	*Zip
*Country	<%= $country_html %>
Day Phone
Night Phone
Fax

* required fields

<%= my $first_payby = $packages->[0]{'payby'}[0]; unless ( grep { scalar( @{$_->{'payby'}} ) > 1 || $_->{'payby'}->[0] ne $first_payby } @$packages ) { @payby = ( $first_payby ); } unless ( scalar(@payby) == 1 && $payby[0] eq 'BILL' ) { $OUT .= ' Billing information '; $OUT .= '' if scalar(@payby) > 1; $OUT .= '

Billing type

'; } else { $OUT .= ' '; } %> <%= 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' => <<'END', END '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' => <<'END', END '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 .= '"; } else { $OUT .= qq!!; } else { $OUT .= qq!> $payby{$_}!; } } } %>

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

$paybychecked{$_}

<%= unless ( scalar(@payby) == 1 && $payby[0] eq 'BILL' ) { $OUT .= '* required fields for each billing type'; } ''; %>

First package <%= if ( $init_data->{'security_phrase'} ) { $OUT .= < ENDOUT } else { $OUT .= ''; } %> <%= if ( scalar(@$pops) ) { $OUT .= ''; } else { $OUT .= popselector($popnum); } %>

<%= $OUT .= '(none)' unless scalar(@$packages) == 1; foreach my $package ( @{$packages} ) { $OUT .= '{'pkgpart'} == $pkgpart ) || scalar(@$packages) == 1; $OUT .= '>'. $package->{'pkg'}; } %>
Username
Password
Re-enter Password
Security Phrase
Access number	'. popselector($popnum). '