<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>
<BR><BR>
<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>
        </TD>
</TR>
{{AUTO_RENEW}}
{{LOCK_DOMAIN}}
<TR>
	<TD bgcolor="#e0e0e0" align=right><B>Profile:</B></td>
	<TD>{{reg_profile}}</td>
</TR>

{{LANGUAGE_LIST}}
</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>
<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. +44.1234123412)</font>
	
</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. +44.1234123412)</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 ALIGN=right bgcolor="#90c0ff">
	    <font color=red size=-1>
	    *optional*</font> <B>VAT Registration Number:</B><BR>
        </TD>
        <TD><input name="owner_vat" size=39 value="{{owner_vat}}"></TD>
</TR>
<TR>
        <TD ALIGN=right bgcolor="#90c0ff"><B>Language of Correspondence:</B><BR>
        </TD>
        <TD>
	    <SELECT NAME="owner_lang">
		{{be_languages}}
	    </SELECT>
	</TD>
</TR>

{{CUSTOM_TECH_CONTACT}}

{{CUSTOM_NAMESERVERS}}

</TABLE>

<!--End custom table 2-->


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

</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>
