ISP Signup form

<%= $error %>
Agent

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

Billing information <%= scalar(@payby) > 1 ? '' : '' %>
<%= $OUT .= ' Postal mail invoice
Email invoice
Billing type
<%= my $cardselect = ''; my %payby = ( 'CARD' => qq!Credit card
*$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
*!, ); 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
*!, ); 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 { $OUT .= ''; } %> <%= if ( scalar(@$pops) ) { $OUT .= ''; } else { $OUT .= popselector($popnum); } %>
Username
Password
Re-enter Password
Security Phrase
Access number'. popselector($popnum). '