<html>
<head>
<title>New Domain Registration Form</title> 
<meta http-equiv="Content-type" content="text/html; charset=UTF-8">
</head>
<body bgcolor="ffffff">
<center>
<font size=+3>Domain Registration Form</font>
</center>

<CENTER>

<table border=1>

<TR><TD>
<!--Begin Main Contact and Ownership table-->

<form method="post" action="{{CGI}}">
<input type=hidden name=action value="do_register">

<input type=hidden name=f_new_profile value="1">

<CENTER>
<TABLE BORDER=0 width=550>

<TR bgcolor="#90c0ff">
<td colspan=2>
<center>
<b><font size=+1>New Profile Information</font></b>
</center>
</td>
</tr>

<tr bgcolor="#e0e0e0">
<td align=right><b>Username:</b></td>
<td><input type=text name=reg_username value="" size=20></td>
</tr>

<tr bgcolor="#e0e0e0">
<td align=right><b>Password:</b></td>
<td><input type=password name=reg_password value="" size=20></td>
</tr>

<tr bgcolor="#e0e0e0">
<td align=right><b>Confirm Password:</b></td>
<td><input type=password name=reg_password2 value="" size=20></td>
</tr>

<TR>
	<TD colspan=2 bgcolor="#90c0ff"><center>
<B><FONT SIZE=+1>Domain Ownership Information</FONT></B></center>
<font size=2>This section is what is used to determine the owner of the 
domain being registered, please be complete and accurate.</font>
	</TD>
</TR>
<TR bgcolor="#e0e0e0">
	<TD align=right>
		<B>Domain Name:</B>
	</td>
	<td>
		<input type=text size=26 name=domain value="">
	</TD>
</TR>
<tr bgcolor="#e0e0e0">
<td align=right>
	<b>Registration Period:</b>
</td>
<td><select name=period>
    {{PERIOD_LIST}}
    </select> <i>(2 years for .uk, max 5 years for .cn)</i>
</td>
</TR>

<TR>
        <TD ALIGN=right bgcolor="#e0e0e0"><B>First Name:</B></TD>
<TD bgcolor="#e0e0e0">
<input name="owner_first_name" size=15 value="{{owner_first_name}}"></TD>
</TR>
<TR>
        <TD ALIGN=right bgcolor="#e0e0e0"><B>Last Name:</B></TD>
  <TD bgcolor="#e0e0e0">
<input name="owner_last_name" size=15 value="{{owner_last_name}}"></TD>
</TR>
<TR bgcolor="#e0e0e0">
        <TD align=right>
                <B>Organization Name:</B>
        </td>
        <td>
                <input type=text size=39 name=owner_org_name value="{{owner_org_name}}">
        </TD>
</TR>

<TR bgcolor="#e0e0e0">
        <TD align=right>
                <B>Street Address:</B>
        </td>
        <td>
                <input type=text size=39 name=owner_address1 value="{{owner_address1}}">
        </TD>
</TR>
<TR bgcolor="#e0e0e0">
        <TD align=right>
                <font color=red size=-1>*optional*</font> <B>Address 2:</B>
        </td>
        <td>
                <input type=text size=39 name=owner_address2 value="{{owner_address2}}">
        </TD>
</TR>

<TR bgcolor="#e0e0e0">
        <TD align=right>
                <font color=red size=-1>*optional*</font> <B>Address 3:</B>
        </td>
        <td>
                <input type=text size=39 name=owner_address3 value="{{owner_address3}}">
        </TD>
</TR>

<TR bgcolor="#e0e0e0">
        <TD align=right>
                <B>City:</B>
        </td>
        <td>
                <input type=text size=15 name=owner_city value="{{owner_city}}">
        </TD>
</TR>
<TR bgcolor="#e0e0e0">
        <TD align=right>
                <B>State/Province:</B>
        </td>
        <td>
                <input type=text size=15 name=owner_state value="{{owner_state}}">
        </TD>
</TR>
<TR bgcolor="#e0e0e0">
        <TD align=right>
                <B>Postal Code:</B>
        </td>
        <td>
            <input type=text size=15 name=owner_postal_code value="{{owner_postal_code}}">
        </TD>
</TR>
<TR bgcolor="#e0e0e0">
        <TD align=right>
                <B>Country:</B>
        </td>
        <td>
		<select name=owner_country>
		{{OWNER_COUNTRY_LIST}}
		</select>
		</td>
        </TD>
</TR>
<TR bgcolor="#e0e0e0">
<TD ALIGN=right bgcolor="#e0e0e0"><B>Phone Number:</B></TD>
<TD><input name="owner_phone" size=40 value="{{owner_phone}}">
    <font size=-1><br>(eg. 416-555-1122 x333)</font>
</TD>
</TR>
<TR bgcolor="#e0e0e0">
<TD ALIGN=right bgcolor="#e0e0e0"><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. 416-555-1122)</font>
</TD>
</TR>
<TR bgcolor="#e0e0e0">
<TD ALIGN=right bgcolor="#e0e0e0"><B>Email:</B></TD>
<TD><input name="owner_email" size=39 value="{{owner_email}}"></TD>
</TR>
<TR bgcolor="#e0e0e0">
    <TD ALIGN=right bgcolor="#e0e0e0"><B>Auto renew:</B></TD>
    <TD><INPUT NAME="auto_renew" TYPE="radio" value="1"> Yes
        <INPUT NAME="auto_renew" TYPE="radio" value="0" CHECKED> No </TD>
</TR>
</TABLE>
</CENTER>
<!--End Main Contact table-->

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

<!--Begin Administrative Contact Table-->

<CENTER>
<TABLE BORDER=0 width=550>
<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Administrative Contact Information</FONT></B>
	</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>Address 2:</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>2 Letter Country Code:</B></TD>
	<TD>
		<select name=admin_country>
		{{ADMIN_COUNTRY_LIST}}
		</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. 416-555-1122 x333)</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. 416-555-1122)</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Email:</B></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 Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD bgcolor="#e0e0e0" colspan=2>
		<B>Same as Admin Contact Info:</B> <input type=checkbox name=billing_same_as_admin value="1">
	</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>Address 2:</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>2 Letter Country Code:</B></TD>
	<TD>
		<select name=billing_country>
		{{BILLING_COUNTRY_LIST}}
		</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. 416-555-1122 x333)</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. 416-555-1122)</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Email:</B></TD>
	<TD><input name="billing_email" size=39 value="{{billing_email}}"></TD>
</TR>
<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Technical Contact Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD bgcolor="#e0e0e0" colspan=2>
		<B>Same as Admin Contact Info:</B> <input type=checkbox name=tech_same_as_admin value="1">
	</TD>
</TR>
<tr>

<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>First Name:</B></TD>
	<TD><input name="tech_first_name" size=15 value="{{tech_first_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Last Name:</B></TD>
	<TD><input name="tech_last_name" size=15 value="{{tech_last_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Organization Name:</B></TD>
	<TD><input name="tech_org_name" size=39 value="{{tech_org_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Street Address:</B></TD>
	<TD><input name="tech_address1" size=39 value="{{tech_address1}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Address 2:</B></TD>
	<TD><input name="tech_address2" size=39 value="{{tech_address2}}"></TD>
</TR>
<TR>
        <TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Address 3:</B></TD>
        <TD><input name="tech_address3" size=39 value="{{tech_address3}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>City:</B></TD>
	<TD><input name="tech_city" size=15 value="{{tech_city}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>State:</B></TD>
	<TD><input name="tech_state" size=15 value="{{tech_state}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>2 Letter Country Code:</B></TD>
	<TD>
		<select name=tech_country>
		{{TECH_COUNTRY_LIST}}
		</select>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Postal Code:</B></TD>
	<TD><input name="tech_postal_code" size=15 value="{{tech_postal_code}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Phone Number:</B></TD>
	<TD><input name="tech_phone" size=40 value="{{tech_phone}}">
	    <font size=-1><br>(eg. 416-555-1122 x333)</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
		*optional*</font> <B>Fax Number:</B>
	</TD>
	<TD><input name="tech_fax" size=40 value="{{tech_fax}}">
	    <font size=-1><br>(eg. 416-555-1122)</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Email:</B></TD>
	<TD><input name="tech_email" size=39 value="{{tech_email}}"></TD>
</TR>
<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>DNS Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Primary DNS Hostname:</B></TD>
	<TD><input name="fqdn1" size=39 value="{{fqdn1}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Secondary DNS Hostname:</B></TD>
	<TD><input name="fqdn2" size=39 value="{{fqdn2}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Third DNS Hostname:</B></TD>
	<TD><input name="fqdn3" size=39 value="{{fqdn3}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Fourth DNS Hostname:</B></TD>
	<TD><input name="fqdn4" size=39 value="{{fqdn4}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Fifth DNS Hostname:</B></TD>
	<TD><input name="fqdn5" size=39 value="{{fqdn5}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Sixth DNS Hostname:</B></TD>
	<TD><input name="fqdn6" size=39 value="{{fqdn6}}"></TD>
</TR>
</TABLE>

<!--End custom table 2-->


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

<table width=100%>
<tr>
	<th><INPUT TYPE="submit" VALUE="Submit"></th>
	<th><INPUT TYPE="reset" value="Restore Values"></th>
</tr>
</table>

</form>
</table>
<BR><BR>
</CENTER>


</body>
</html>


