<center><Font size=+2><B>Domain {{reg_text}} - 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 BORDER=0 width=550>
<TR>
	<TD ALIGN=center colspan=2 bgcolor="#e0e0e0">
		<B><FONT SIZE=+1>Domain Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Domains Desired:</B></TD>
	<TD>{{domains}}</TD>
</TR>
<TR>
        <TD align=right bgcolor="#e0e0e0"><b>Registration Period:</b></td>
        <TD><select name=period>
            {{PERIOD_LIST}}
            </select>
        {{reg_period_hints}}
        </TD>
</TR>
{{AUTO_RENEW}}
{{LOCK_DOMAIN}}
<TR>
	<TD bgcolor="#e0e0e0" align=right><B>Profile:</B></td>
	<TD>{{reg_profile}}</td>
</tr>
</TABLE>

<!--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>



    <!-- Javascript for hiding/showing relevant boxes -->
    <script type="text/javascript">
        var timerId;

        function showHideOther(selectBoxId,showHideId,inputBoxId) {
            // Show or hide the specified section depending on whether the "other" type is selected...
            var selectObj=document.getElementById(selectBoxId);
            var showHideObj=document.getElementById(showHideId);
            var inputBoxObj=document.getElementById(inputBoxId);
            if(selectObj.value=='other') {
                showHideObj.style.display='';
            } else {
                showHideObj.style.display='none';
                inputBoxObj.value='';
            }
        }
        function _showOptional(showHideControlId,showHideIds,clearIds) {
                for(i=0;i<showHideIds.length;i++) {
                    var showHideObj=document.getElementById(showHideIds[i]);
                    showHideObj.style.display='';
                }
                document.getElementById(showHideControlId).innerHTML='[-]';
        }
        function _hideOptional(showHideControlId,showHideIds,clearIds) {
                for(i=0;i<showHideIds.length;i++) {
                    var showHideObj=document.getElementById(showHideIds[i]);
                    showHideObj.style.display='none';
                }
                for(i=0;i<clearIds.length;i++) {
                    var clearObj=document.getElementById(clearIds[i]);
                    clearObj.value='';
                }
                document.getElementById(showHideControlId).innerHTML='[+]';
        }
        function toggleOptionalSections(showHideControlId,showHideIds,clearIds) {
            // Show or hide the specified section depending on whether the "other" type is selected...
            if(document.getElementById(showHideControlId).innerHTML=='[+]') {
                _showOptional(showHideControlId,showHideIds,clearIds);
            } else {
                _hideOptional(showHideControlId,showHideIds,clearIds);
            }
        }
        function initialShowHide() {
            if((document.getElementById('ced_locality_city').value=='')&&(document.getElementById('ced_locality_state_prov').value=='')) {
                _hideOptional('ced_locality_country_expand'
                    ,['ced_locality_city_input','ced_locality_state_prov_input']
                    ,[]);
            } else {
                _showOptional('ced_locality_country_expand'
                    ,['ced_locality_city_input','ced_locality_state_prov_input']
                    ,[]);
            }

            showHideOther('ced_legal_entity_type','ced_legal_entity_type_info_input','ced_legal_entity_type_info');
            showHideOther('ced_id_type','ced_id_type_info_input','ced_id_type_info');

            clearTimeout(timerId);
        }
    </script>

<TR>
  <TD COLSPAN="2" bgcolor="#90c0ff" align=center>
    <B><FONT SIZE="+1">.ASIA CED Contact Information</FONT></B>
  </TD>
</TR>
<TR>
  <TD ALIGN=left VALIGN="top" bgcolor="#e0e0e0" class="main">
    Contact Type
  </TD>
  <TD>
    <SELECT ID="ced_contact_type" NAME="ced_contact_type">
      {{CED_CONTACT_TYPE_LIST}}
    </SELECT>

    <FONT SIZE="-1"><BR><BR>Charter Eligibility is the basic requirement
    to register a .ASIA domain name, at least one of the domain contacts (admin,
    billing, owner/registrant, tech) must be a legal entity in the DotAsia
    Community.</FONT>

  </TD>
</TR>
<TR>
  <TD ALIGN=left VALIGN="top" bgcolor="#e0e0e0" class="main">
    Country/Locality
  </TD>
  <TD>
    <SELECT ID="ced_locality_country" NAME="ced_locality_country">
      {{CED_LOCALITY_COUNTRY_LIST}}
    </SELECT>
    </SELECT>&nbsp;<font size="1"><a id="ced_locality_country_expand" style="cursor: pointer;" onClick="toggleOptionalSections(this.id,['ced_locality_city_input','ced_locality_state_prov_input'],['ced_locality_city','ced_locality_state_prov']);">[-]</a></font></td>
  </TD>
</TR>
<TR id="ced_locality_city_input">
  <TD ALIGN=left VALIGN="top" bgcolor="#e0e0e0" class="main">
    City<br>
    <font color="red" size="-1">*optional*</font>
  </TD>
  <TD>
    <INPUT TYPE="edit" ID="ced_locality_city" NAME="ced_locality_city" VALUE="{{ced_locality_city}}">
  </TD>
</TR>
<TR id="ced_locality_state_prov_input">
  <TD ALIGN=left VALIGN="top" bgcolor="#e0e0e0" class="main">
    State/Province<br>
    <font color="red" size="-1">*optional*</font>
  </TD>
  <TD>
    <INPUT TYPE="edit" ID="ced_locality_state_prov" NAME="ced_locality_state_prov" VALUE="{{ced_locality_state_prov}}">
  </TD>
</TR>
<TR>
  <TD ALIGN=left VALIGN="top" bgcolor="#e0e0e0" class="main">
    Legal Entity Type
  </TD>
  <TD>
    <SELECT ID="ced_legal_entity_type" NAME="ced_legal_entity_type" onChange="showHideOther(this.id,'ced_legal_entity_type_info_input','ced_legal_entity_type_info');">
      {{CED_LEGAL_ENTITY_TYPE_LIST}}
    </SELECT>
    <DIV ID="ced_legal_entity_type_info_input">
      <FONT SIZE="-1">
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Type: <INPUT TYPE="edit" ID="ced_legal_entity_type_info" NAME="ced_legal_entity_type_info" VALUE="{{ced_legal_entity_type_info}}">
      </FONT>
    </DIV>
  </TD>
</TR>
<TR>
  <TD ALIGN=left VALIGN="top" bgcolor="#e0e0e0" class="main">
    Identification Type
  </TD>
  <TD>
    <select ID="ced_id_type" NAME="ced_id_type" onChange="showHideOther(this.id,'ced_id_type_info_input','ced_id_type_info');">
      {{CED_ID_TYPE_LIST}}
    </SELECT>
    <DIV ID="ced_id_type_info_input">
      <FONT SIZE="-1">
        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Type: <INPUT TYPE="edit" ID="ced_id_type_info" NAME="ced_id_type_info" VALUE="{{ced_id_type_info}}">
      </FONT>
    </DIV>
  </TD>
</TR>
<TR>
  <TD ALIGN=left VALIGN="top" bgcolor="#e0e0e0" class="main">
    Identification Number
  </TD>
  <TD>
    <INPUT TYPE="edit" ID="ced_id_number" NAME="ced_id_number" VALUE="{{ced_id_number}}">
  </TD>
</TR>
<BR>

    <script type="text/javascript">
        // Once the page is loaded, make sure we hide/show the appropriate fields (depending on our selection)
        // (it's on a timer so that certain browsers have time to put the data back in the forms when clicking the "back" button)
        timerId=setTimeout("initialShowHide()",1000);
    </script>



<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>
	</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><br>
		<B>Same as Admin Information</B> <input type=checkbox name=flag_billing_use_admin_info><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-->

</TD></TR>

{{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=" C L E A R "></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>
{{domain_string}}
<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=reg_type value="{{reg_type}}">
<input type=hidden name=bulk_order value="{{bulk_order}}">
</form>
<BR>
