<center><Font size=+2><B>{{heading}} - Order Form</B></FONT></center>

<BLOCKQUOTE>
Congratulations on your decision to move forward with your business 
and register your own domain name.  
Upon completing the form below, you will be brought to a second 
page where you may verify that all of the information you have
provided is correct.
After you approve the information, simply click the "Order It!" 
button and you're done.
</BLOCKQUOTE>

<center><FONT color = red><B>{{syntax_error_msg}} </B></FONT></center>

<CENTER>
<table border=1>

<form method=post action="{{CGI}}">

<TR><TD>

<!--Begin revision and colored table-->

<table width=100%>
      <tr>
	<th><INPUT TYPE="submit" VALUE=" V E R I F Y    O R D E R "></th>
	<th><INPUT TYPE="reset" value=" R E S E T "></th>
      </tr>
</table>

<TABLE BORDER=0 width=550>
<TR>
	<TD ALIGN=center colspan=2 bgcolor="#e0e0e0">
		<B><FONT SIZE=+1>Domain Information</FONT></B>
	</TD>
</TR>
<TR bgcolor="e0e0e0">
    <TD align=right>
        <B>Domains:</B>
    </TD>
    <TD>
        <textarea name=domains cols=20 rows=5>{{domains}}</textarea>
    </TD>
</TR>
<TR>
        <TD align=right bgcolor="#e0e0e0"><b>Registration Period:</b></td>
        <TD><select name=period>
            {{PERIOD_LIST}}
            </select>
	    <i>(min 2 years for .us)</i><br>
        </TD>
</TR>
{{AUTO_RENEW}}
<TR>
	<TD bgcolor="#e0e0e0" align=right><B>Profile:</B></td>
	<TD>{{reg_profile}}</td>
</tr>
</TABLE>
</CENTER>
<!--End First custom table-->

</TR></TD>
<TR><TD>

<!--Begin 2nd revision and colored table-->

<TABLE BORDER=0 width=550>
<TR>
	<TD colspan=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Registration Type:</b> <font color=red>{{reg_type_text}}</font></font>
	</TD>
</TR>

<TR bgcolor="#90c0ff">
	<TD ALIGN=center colspan=2>
		<B><FONT SIZE=+1>.US Nexus Information</FONT></B>
	</TD>
</TR>

             <TR>
               <TD align=right bgcolor="e0e0e0" CLASS="main">
                 Domain Name Application Purpose
               </TD>
               <TD CLASS="main">
                 <SELECT NAME="app_purpose">
		    {{APP_PURPOSE_LIST}}
                 </SELECT>
               </TD>
             </TR>
             <TR>
               <TD align=right bgcolor="e0e0e0" CLASS="main">
                  Nexus Category of Applicant
                  <FONT SIZE="-1">
                    (please choose one)
                  </FONT>
               </TD>
               <TD CLASS="main">
                  <FONT SIZE="+1">Category 1 - A natural person:</FONT>
                  <BR>
                  <INPUT TYPE="radio" NAME="nexus_category" VALUE="C11" {{CATEGORY_C11}}>Who is a United States citizen 
                  <BR>
                  <INPUT TYPE="radio" NAME="nexus_category" VALUE="C12" {{CATEGORY_C12}}>Who is a permanent resident of the United States of America or any of its possessions or territories
                  <BR>
                  <HR WIDTH="100%">
                  <FONT SIZE="+1">Category 2 - U.S. Corporation</FONT>
                  <BR>
                  <INPUT TYPE="radio" NAME="nexus_category" VALUE="C21" {{CATEGORY_C21}}>U.S. organization incorporated within one of the 50 states of a U.S. territory
                  <BR>
                  <HR WIDTH="100%">
                  <FONT SIZE="+1">Category 3 - Bona Fide U.S. Presence</FONT>
                  <BR>
                  <INPUT TYPE="radio" NAME="nexus_category" VALUE="C31" {{CATEGORY_C31}}>Regularly engages in lawful activities (sales of good or services or other business, commercial or non-commercial, including not-for-profit relations in the United States).
                  <BR>
                  <INPUT TYPE="radio" NAME="nexus_category" VALUE="C32" {{CATEGORY_C32}}>Entity has an office or other facility in the U.S.
                  <BR>
                  <B>Country of Citizenship: (required for Category 3)</B>&nbsp;&nbsp;
                  <SELECT NAME="nexus_validator">
                    <OPTION VALUE="">---- Select Country ----
                    {{CITIZEN_COUNTRY_LIST}}
                  </SELECT>
               </TD>
             </TR>

<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Owner Contact Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>First Name:</B></TD>
	<TD><input name="owner_first_name" size=15 value="{{owner_first_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Last Name:</B></TD>
	<TD><input name="owner_last_name" size=15 value="{{owner_last_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Organization Name:</B></TD>
	<TD><input name="owner_org_name" size=39 value="{{owner_org_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Street Address:</B></TD>
	<TD><input name="owner_address1" size=39 value="{{owner_address1}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>(eg: Suite #245):</B></TD>
	<TD><input name="owner_address2" size=39 value="{{owner_address2}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Address 3:</B></TD>
	<TD><input name="owner_address3" size=39 value="{{owner_address3}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>City:</B></TD>
	<TD><input name="owner_city" size=15 value="{{owner_city}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>State:</B></TD>
	<TD><input name="owner_state" size=15 value="{{owner_state}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Country:</B></TD>
	<TD><SELECT NAME="owner_country">
{{country_menu}}
 </SELECT></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Postal Code:</B></TD>
	<TD><input name="owner_postal_code" size=15 value="{{owner_postal_code}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Phone Number:</B></TD>
	<TD><input name="owner_phone" size=40 value="{{owner_phone}}">
	    <font size=-1><br>(eg. +1.4165551122x333)*</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
		*optional*</font> <B>Fax Number:</B>
	</TD>
	<TD><input name="owner_fax" size=40 value="{{owner_fax}}">
	    <font size=-1><br>(eg. +1.4165551122)*</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Email:</B><BR>
	    <FONT color=red size=-1>Must be currently valid address</FONT>
	</TD>
	<TD><input name="owner_email" size=39 value="{{owner_email}}"></TD>
</TR>
<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Admin Contact Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD COLSPAN=2 bgcolor="e0e0e0" align=center>
		<B>Same as Owner Information</B> <input type=checkbox name=flag_admin_use_contact_info value=1><br>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>First Name:</B></TD>
	<TD><input name="admin_first_name" size=15 value="{{admin_first_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Last Name:</B></TD>
	<TD><input name="admin_last_name" size=15 value="{{admin_last_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Organization Name:</B></TD>
	<TD><input name="admin_org_name" size=39 value="{{admin_org_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Street Address:</B></TD>
	<TD><input name="admin_address1" size=39 value="{{admin_address1}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>(eg: Suite #245):</B></TD>
	<TD><input name="admin_address2" size=39 value="{{admin_address2}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Address 3:</B></TD>
	<TD><input name="admin_address3" size=39 value="{{admin_address3}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>City:</B></TD>
	<TD><input name="admin_city" size=15 value="{{admin_city}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>State:</B></TD>
	<TD><input name="admin_state" size=15 value="{{admin_state}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Country:</B></TD>
	<TD><SELECT NAME="admin_country">
{{admin_country_menu}}
 </SELECT></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Postal Code:</B></TD>
	<TD><input name="admin_postal_code" size=15 value="{{admin_postal_code}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Phone Number:</B></TD>
	<TD><input name="admin_phone" size=40 value="{{admin_phone}}">
	    <font size=-1><br>(eg. +1.4165551122x333)*</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
		*optional*</font> <B>Fax Number:</B>
	</TD>
	<TD><input name="admin_fax" size=40 value="{{admin_fax}}">
	    <font size=-1><br>(eg. +1.4165551122)*</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Email:</B><BR>
	    <FONT color=red size=-1>Must be currently valid address</FONT>
	</TD>
	<TD><input name="admin_email" size=39 value="{{admin_email}}"></TD>
</TR>
<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Billing Contact Information</FONT></B>
	</TD>
</TR>

<TR>
	<TD COLSPAN=2 bgcolor="e0e0e0" align=center>
		<B>Same as Owner Information</B> <input type=checkbox name=flag_billing_use_contact_info value=1><br>
		<B>Same as Admin Information</B> <input type=checkbox name=flag_billing_use_admin_info value=1><br>
		<font color=red size=-1>If both checkboxes are selected, 'Owner Information' checkbox will be default.</font><br>	
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>First Name:</B></TD>
	<TD><input name="billing_first_name" size=15 value="{{billing_first_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Last Name:</B></TD>
	<TD><input name="billing_last_name" size=15 value="{{billing_last_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Organization Name:</B></TD>
	<TD><input name="billing_org_name" size=39 value="{{billing_org_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Street Address:</B></TD>
	<TD><input name="billing_address1" size=39 value="{{billing_address1}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>(eg: Suite #245):</B></TD>
	<TD><input name="billing_address2" size=39 value="{{billing_address2}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Address 3:</B></TD>
	<TD><input name="billing_address3" size=39 value="{{billing_address3}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>City:</B></TD>
	<TD><input name="billing_city" size=15 value="{{billing_city}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>State:</B></TD>
	<TD><input name="billing_state" size=15 value="{{billing_state}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Country:</B></TD>
	<TD><SELECT NAME="billing_country">
{{billing_country_menu}}
 </SELECT></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Postal Code:</B></TD>
	<TD><input name="billing_postal_code" size=15 value="{{billing_postal_code}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Phone Number:</B></TD>
	<TD><input name="billing_phone" size=40 value="{{billing_phone}}">
	    <font size=-1><br>(eg. +1.4165551122x333)*</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
		*optional*</font> <B>Fax Number:</B>
	</TD>
	<TD><input name="billing_fax" size=40 value="{{billing_fax}}">
	    <font size=-1><br>(eg. +1.4165551122)*</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Email:</B><BR>
	    <FONT color=red size=-1>Must be currently valid address</FONT>
	</TD>
	<TD><input name="billing_email" size=39 value="{{billing_email}}"></TD>
</TR>

{{CUSTOM_TECH_CONTACT}}

{{CUSTOM_NAMESERVERS}}

</TABLE>

<!--End custom table 2-->


</TR></TD>

{{CC_FIELDS}}

<TR><TD>

<table width=100%>
<tr>
	<th><INPUT TYPE="submit" VALUE=" V E R I F Y    O R D E R "></th>
	<th><INPUT TYPE="reset" value=" R E S E T "></th>
</tr>
</table>

</table>
<BR>
</CENTER>

<br><pre>
* - Phone and fax formats are as follows (extention is optional):
    +{country_dialing_code}.{phone_number}[x{extension}]
    eg. "+44.02055511928"
<pre>

<input type=hidden name=affiliate_id value="{{affiliate_id}}">
<input type=hidden name=action value="verify_order">
<input type=hidden name=bulk_order value="{{bulk_order}}">
<input type=hidden name=reg_type value="{{reg_type}}">
<input type=hidden name=reg_username value="{{reg_username}}">
<input type=hidden name=reg_password value="{{reg_password}}">
<input type=hidden name=reg_domain value="{{reg_domain}}">
</form>
<BR>
