<center><Font size=+2><B><font color=red>.CA</font> {{heading}} - Order Form</B></FONT></center>

<BLOCKQUOTE>
Congratulations on your decision to move forward with your business 
and register your own <font color=red>.CA</font> 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.
<P>
<I>Please note that the domains in the batch below will be added to ONE
Registrant Profile at CIRA. The names will also be in the same profile for
contact and DNS management.</I>
<P>
</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-->
<CENTER>
    <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>
        </TD>
</TR>
<TR>
	<TD bgcolor="#e0e0e0" align=right><B>Profile:</B></td>
	<TD>The names above will be added to the CIRA Registrant Profile that
contains the name {{reg_domain}}&nbsp;</td>
</tr>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Owner name</B></TD>
	<TD><input name="owner_org_name" type="hidden" value="{{owner_org_name}}">{{owner_org_name}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Owner Description</B>
	    <I>(max 2000 characters)</I></TD>
	<TD>
	    {{domain_description}}
	    <input type="hidden" name="domain_description" value="{{domain_description}}">&nbsp;
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Are these domains registered trade-marks?</B></TD>
	<TD>
	    <input type="radio" name="isa_trademark" value="0" checked>No&nbsp;
	    <input type="radio" name="isa_trademark" value="1">Yes
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Language Preference:</B></TD>
	<TD>
	    <select name="lang_pref">
		    <option value="EN">English
		    <option value="FR">Français
	    </select>
	</TD>
</TR>
<input type="hidden" name="legal_type" value="{{legal_type}}">
</TABLE>
</CENTER>
<!--End First custom table-->

</TR></TD>

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

<CENTER>
<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>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Admin Contact Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>First Name:</B></TD>
	<TD><input type="hidden" name="admin_first_name" value="{{admin_first_name}}">{{admin_first_name}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Last Name:</B></TD>
	<TD><input type="hidden" name="admin_last_name" value="{{admin_last_name}}">{{admin_last_name}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Organization Name:</B></TD>
	<TD><input type="hidden" name="admin_org_name" value="{{admin_org_name}}">{{admin_org_name}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Street Address:</B></TD>
	<TD><input type="hidden" name="admin_address1" value="{{admin_address1}}">{{admin_address1}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>City:</B></TD>
	<TD><input type="hidden" name="admin_city" value="{{admin_city}}">{{admin_city}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>State:</B></TD>
	<TD><input type="hidden" name="admin_state" value="{{admin_state}}">{{admin_state}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Country:</B></TD>
	<TD><input type="hidden" name="admin_country" value="{{admin_country}}">{{admin_country}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Postal Code:</B></TD>
	<TD><input type="hidden" name="admin_postal_code" value="{{admin_postal_code}}">{{admin_postal_code}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Phone Number:</B></TD>
	<TD><input type="hidden" name="admin_phone" value="{{admin_phone}}">{{admin_phone}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Fax Number:</B></TD>
	<TD><input type="hidden" name="admin_fax" size=40 value="{{admin_fax}}">{{admin_fax}}&nbsp;</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Email:</B></TD>
	<TD><input type="hidden" name="admin_email" value="{{admin_email}}">
{{admin_email}}&nbsp;</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>

<input type=hidden name=affiliate_id value="{{affiliate_id}}">
<input type=hidden name=action value="verify_order">
<input type=hidden name=bulk_order value="1">
<input type=hidden name=reg_type value="new">
<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}}">
<input type=hidden name=domain_country value="ca">
</form>
<BR>
