<center>

Step 1: Digital Certificate Product Selection.<br>
<b>Step 2: Enter Product Order Details.</b><br>
Step 3: Credit Card Information. Order Confirmation.<br>
<p>

<TMPL_IF errors>
    <font color=red size=+1><b>Errors occurred:</b></font><br>
	<TMPL_VAR errors>
</TMPL_IF>

<form action="<TMPL_VAR NAME=cgi>" method="post">
<input type=hidden name="action" value="verify_data">
<input type=hidden name="reg_type" value="<TMPL_VAR NAME=reg_type>">
<input type=hidden name="id" value="<TMPL_VAR NAME=id>">

<table border="0" cellpadding="5" cellspacing="1">
<tr>
    <td class="main" colspan=2 align=center>
	<font class="heading">New Digital Certificate Order Form</font>
    </td>
</tr>

<tr>
    <td class="accent" align="center" colspan=2><b>Product Information</b></td>
</tr>
<tr>
    <td class="accent" align="right">Product:</td>
    <td class="accent" align="left"><TMPL_VAR NAME=product_name>
	<input type=hidden name="product" value="<TMPL_VAR NAME=product>">
    </td>
</tr>

<TMPL_IF domain>
<tr>
    <td class="accent" align="right">Domain:</td>
    <td class="accent" align="left"><TMPL_VAR NAME=domain>
	<input type=hidden name="domain" value="<TMPL_VAR NAME=domain>">
    </td>
</tr>
</TMPL_IF>

<TMPL_IF approvers_select>
<tr>
    <td class="accent" align="right">Approver E-mail:</td>
    <td class="accent" align="left"><select name=approver_email size=1>
	    <TMPL_VAR NAME=approvers_select>
	</select>
    </td>
</tr>
</TMPL_IF>

<tr>
    <td class="accent" align="right">Period:</td>
    <td class="accent" align="left"><select name="period" size=1>
	    <TMPL_VAR NAME=period_select>
	</select>
    </td>
</tr>

<TMPL_IF organization_contact>
<tr>
    <td class="accent" align=left colspan=2><b>Organization Contact:</b>
    <select name="organization_contact_id">
	<option value="">Please Select Contact
	<TMPL_VAR NAME=organization_contact_select>
    </select>
    - or -
    </td>
</tr>
<tr>
    <td class="accent" align="right">Organization Legal Name:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_org_name"
	value="<TMPL_VAR NAME=organization_org_name>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">DUNS Number:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_duns" value="<TMPL_VAR NAME=organization_duns>"
	size=25 maxlength=100>&nbsp;&nbsp;
	<font size="-1" color="red"><i>optional</i></font>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Street Address 1:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_address1"
	value="<TMPL_VAR NAME=organization_address1>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Street Address 2:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_address2"
	value="<TMPL_VAR NAME=organization_address2>" size=25
	maxlength=99>&nbsp;&nbsp;
	<font size="-1" color="red"><i>optional</i></font>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Street Address 3:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_address3"
	value="<TMPL_VAR NAME=organization_address3>" size=25
	maxlength=99>&nbsp;&nbsp;
	<font size="-1" color="red"><i>optional</i></font>
    </td>
</tr>
<tr>
    <td class="accent" align="right">City:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_city"
	value="<TMPL_VAR NAME=organization_city>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">State/Province:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_state"
	value="<TMPL_VAR NAME=organization_state>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Zip/Postal Code:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_postal_code"
	value="<TMPL_VAR NAME=organization_postal_code>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Country:</td>
    <td class="accent" align="left">
	<select name="organization_country">
	    <TMPL_VAR NAME=organization_country_select>
	</select>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Phone:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_phone"
	value="<TMPL_VAR NAME=organization_phone>"
	size=25 maxlength=25>&nbsp;&nbsp;
	<font size="-1">(eg. +1.4165551122x1234)</font>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Fax:</td>
    <td class="accent" align="left"><input type=textbox
	name="organization_fax" value="<TMPL_VAR NAME=organization_fax>"
	size=25 maxlength=25>&nbsp;&nbsp;
	<font size="-1">(eg. +1.4165551122x1234)</font>
    </td>
</tr>
</TMPL_IF>

<tr>
    <td class="accent" align=left colspan=2><b>Certificate Admin. Contact:</b>
	<select name="admin_contact_id">
	    <option value="">Please Select Contact
	    <TMPL_VAR NAME=admin_contact_select>
	</select>
	- or -
    </td>
</tr>
<tr>
    <td class="accent" align="right">First Name:</td>
    <td class="accent" align="left"><input type=textbox name="admin_first_name"
	value="<TMPL_VAR NAME=admin_first_name>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Last Name:</td>
    <td class="accent" align="left"><input type=textbox name="admin_last_name"
	value="<TMPL_VAR NAME=admin_last_name>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Street Address:</td>
    <td class="accent" align="left"><input type=textbox name="admin_address1"
	value="<TMPL_VAR NAME=admin_address1>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">City:</td>
    <td class="accent" align="left"><input type=textbox name="admin_city"
	value="<TMPL_VAR NAME=admin_city>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">State/Province:</td>
    <td class="accent" align="left"><input type=textbox name="admin_state"
	value="<TMPL_VAR NAME=admin_state>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Zip/Postal Code:</td>
    <td class="accent" align="left"><input type=textbox
	name="admin_postal_code" value="<TMPL_VAR NAME=admin_postal_code>"
	size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Country:</td>
    <td class="accent" align="left">
	<select name="admin_country">
	    <TMPL_VAR NAME=admin_country_select>
	</select>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Phone:</td>
    <td class="accent" align="left"><input type=textbox
	name="admin_phone" value="<TMPL_VAR NAME=admin_phone>"
	size=25 maxlength=25>&nbsp;&nbsp;
	<font size="-1">(eg. +1.4165551122x1234)</font>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Email:</td>
    <td class="accent" align="left"><input type=textbox name="admin_email"
	value="<TMPL_VAR NAME=admin_email>" size=25 maxlength=100>
    </td>
</tr>

<tr>
    <td class="accent" align=left colspan=2><b>Certificate Billing Contact:</b>
	<select name="billing_contact_id">
	    <option value="">Please Select Contact
	    <TMPL_VAR NAME=billing_contact_select>
	</select>
	- or -
    </td>
</tr>
<tr>
    <td class="accent" align="right">First Name:</td>
    <td class="accent" align="left"><input type=textbox
	name="billing_first_name" value="<TMPL_VAR NAME=billing_first_name>"
	size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Last Name:</td>
    <td class="accent" align="left"><input type=textbox
	name="billing_last_name" value="<TMPL_VAR NAME=billing_last_name>"
	size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Street Address:</td>
    <td class="accent" align="left"><input type=textbox name="billing_address1"
	value="<TMPL_VAR NAME=billing_address1>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">City:</td>
    <td class="accent" align="left"><input type=textbox name="billing_city"
	value="<TMPL_VAR NAME=billing_city>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">State/Province:</td>
    <td class="accent" align="left"><input type=textbox name="billing_state"
	value="<TMPL_VAR NAME=billing_state>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Zip/Postal Code:</td>
    <td class="accent" align="left"><input type=textbox
	name="billing_postal_code" value="<TMPL_VAR NAME=billing_postal_code>"
	size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Country:</td>
    <td class="accent" align="left">
	<select name="billing_country">
	    <TMPL_VAR NAME=billing_country_select>
	</select>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Phone:</td>
    <td class="accent" align="left"><input type=textbox
	name="billing_phone" value="<TMPL_VAR NAME=billing_phone>"
	size=25 maxlength=25>&nbsp;&nbsp;
	<font size="-1">(eg. +1.4165551122x1234)</font>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Email:</td>
    <td class="accent" align="left"><input type=textbox name="billing_email"
	value="<TMPL_VAR NAME=billing_email>" size=25 maxlength=100>
    </td>
</tr>

<tr>
    <td class="accent" align=left colspan=2><b>Certificate Technical
	Contact:</b>
	<select name="tech_contact_id">
	    <option value="">Please Select Contact
	    <TMPL_VAR NAME=tech_contact_select>
	</select>
	- or -
    </td>
</tr>
<tr>
    <td class="accent" align="right">First Name:</td>
    <td class="accent" align="left"><input type=textbox name="tech_first_name"
	value="<TMPL_VAR NAME=tech_first_name>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Last Name:</td>
    <td class="accent" align="left"><input type=textbox name="tech_last_name"
	value="<TMPL_VAR NAME=tech_last_name>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Street Address:</td>
    <td class="accent" align="left"><input type=textbox name="tech_address1"
	value="<TMPL_VAR NAME=tech_address1>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">City:</td>
    <td class="accent" align="left"><input type=textbox name="tech_city"
	value="<TMPL_VAR NAME=tech_city>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">State/Province:</td>
    <td class="accent" align="left"><input type=textbox name="tech_state"
	value="<TMPL_VAR NAME=tech_state>" size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Zip/Postal Code:</td>
    <td class="accent" align="left"><input type=textbox
	name="tech_postal_code" value="<TMPL_VAR NAME=tech_postal_code>"
	size=25 maxlength=100>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Country:</td>
    <td class="accent" align="left">
	<select name="tech_country">
	    <TMPL_VAR NAME=tech_country_select>
	</select>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Phone:</td>
    <td class="accent" align="left"><input type=textbox
	name="tech_phone" value="<TMPL_VAR NAME=tech_phone>"
	size=25 maxlength=25>&nbsp;&nbsp;
	<font size="-1">(eg. +1.4165551122x1234)</font>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Email:</td>
    <td class="accent" align="left"><input type=textbox name="tech_email"
	value="<TMPL_VAR NAME=tech_email>" size=25 maxlength=100>
    </td>
</tr>

<tr>
    <td class="accent" align="center" colspan=2><b>Certificate Signing Request
	Information</b></td>
</tr>
<tr>
    <td class="accent" valign="top" align="right">CSR:
	<br>
	<br>
	<a href="<TMPL_VAR NAME=csr_help_url>" target="_csr_help">CSR
	    Generation Instructions</a></td>
    <td class="accent" align="left">
        <textarea name="csr" cols=65 rows=12><TMPL_IF csr_regenerate_forced>
	Please note that your previous CSR has been removed due to it's webserver type. This type mandates that a new CSR be generated with every new certificate generated.
	<TMPL_ELSE><TMPL_VAR NAME=csr></TMPL_IF></textarea>
    </td>
</tr>
<tr>
    <td class="accent" align="right">Web Server:</td>
    <td class="accent" align="left"><select name="webserver" size=1>
	    <option value="">Not specified
	    <TMPL_VAR NAME=webservers_select>
	</select>
    </td>
</tr>
<tr>
    <td align="right" class="accent" valign=top nowrap>Special
	Instructions:</td>
    <td class="accent"><textarea name="special_instructions"
	cols=65 rows=6><TMPL_VAR NAME=special_instructions></textarea>
    </td>
</tr>
<tr>
    <td class="main" align="center" colspan="2">By submitting this order you
	are agreeing to the&nbsp;
	<i><a href="<TMPL_VAR NAME=agreement_url>"
	    target="_agreement">GeoTrust Subscriber Agreement</a></i>
	<br>
	<input type="submit" value=" Proceed ">
    </td>
</tr>

</table>

</form>

</center>
