
<center>

  <table border="1" cellpadding="3" cellspacing="0" width="50%">
    
    <tr class="accent">
      <td align="center" class="header1" colspan=2>
        Email Defense Contact Information for <TMPL_VAR domain_name>
      </td>
    </tr>
    
    <form action="<TMPL_VAR CGI>" method="post">
    <input type="hidden" name="action" value="do_add_contact_info">
    <input type="hidden" name="session" value="<TMPL_VAR ESCAPE=HTML session>">
    <input type="hidden" name="sign" value="<TMPL_VAR sign>">
    <input type="hidden" name="edit_path" value="<TMPL_VAR edit_path>">

    <tr> 
      <th align=right> <b>Admin Contact:</b> </th>       
      <td> <TMPL_IF edit_path>&nbsp <TMPL_ELSE><select name="admin_contact"> <TMPL_VAR NAME=contact_list> </select> -or- </TMPL_IF></td> 
    </tr>

    <tr> 
        <th align=right> First Name:</th> 
	<td> <input type=text name=first_name  value="<TMPL_VAR first_name>" size=30> </td>
    </tr>

    <tr> 
        <th align=right> Last Name:</th>
	<td> <input type=text name=last_name  value="<TMPL_VAR last_name>" size=30> </td>
    </tr>
    
    <tr> 
        <th align=right> Street Address:</th>
	<td> <input type=text name=address1  value="<TMPL_VAR address1>" size=30> </td>
    </tr>

    <tr> 
        <th align=right> City:</th>
	<td> <input type=text name=city  value="<TMPL_VAR city>" size=30> </td>
    </tr>

    <tr> 
        <th align=right> State/Province:</th>
	<td> <input type=text name=state  value="<TMPL_VAR state>" size=30> </td>
    </tr>

    <tr> 
        <th align=right> Zip/Postal Code:</th>
	<td> <input type=text name=postal_code  value="<TMPL_VAR postal_code>" size=30> </td>
    </tr>

    <tr> 
        <th align=right> Country:</th>
	<td> <select name="country"> <TMPL_VAR NAME=country_menu> </select></td> 
    </tr>
    
    <tr> 
        <th align=right> Phone:</th>
	<td> <input type=text name=phone  value="<TMPL_VAR phone>" size=30> <font size=-1>(e.g. +1.4165551122x1234) </font></td>
    </tr>
    
    <tr> 
        <th align=right> Email:</th>
	<td> <input type=text name=email  value="<TMPL_VAR email>" size=30> </td>
    </tr>
            
    <tr class="soft">
      <td align=right colspan=2>
        <TMPL_IF edit_path><input type=submit name="cancel" value=" Cancel "></TMPL_IF>
        <input type=submit name="do_add_contact_info" value="  Proceed to Confirmation...  ">	    
      </td>
    </tr>
    
  </table>
</form>
</center>
