<TMPL_INCLUDE header.html>
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<table border=1>
<tr><td>

<table border=0 width=550>

  <tr bgcolor=#90c0ff>
    <th align=center colspan=2><font size=+1>Admin Contact Information</font></th>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b><TMPL_IF error_admin_first_name><font color=red><blink>*</blink></font></TMPL_IF> First Name:</b></td>
    <td><input type=text name=admin_first_name value="<TMPL_VAR ESCAPE=HTML admin_first_name>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_last_name><font color=red><blink>*</blink></font></TMPL_IF> Last Name:</b></td>
    <td><input type=text name=admin_last_name value="<TMPL_VAR ESCAPE=HTML admin_last_name>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_pref_language><font color=red><blink>*</blink></font></TMPL_IF> Preferred Language:</b></td>
    <td>
     <select name=admin_pref_language size=1>
      <TMPL_IF admin_pref_language><option value='<TMPL_VAR admin_pref_language>' selected><TMPL_VAR admin_lang_long></TMPL_IF> 
      <option value="">Choose One
      <option value="EN">English
      <option value="FR">Français
     </select>
    </td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_org_name><font color=red><blink>*</blink></font></TMPL_IF> Organization Name:</b></td>
    <td><input type=text name=admin_org_name value="<TMPL_VAR ESCAPE=HTML admin_org_name>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_address1><font color=red><blink>*</blink></font></TMPL_IF> Street:</b></td>
    <td><input type=text name=admin_address1 value="<TMPL_VAR ESCAPE=HTML admin_address1>" size=30></td>
  </tr>
  
  <tr bgcolor=#e0e0e0>
    <td align=right><font size=-1 font color=red>*optional* </font><b>&nbsp</b></td>
    <td><input type=text name=admin_address2 value="<TMPL_VAR ESCAPE=HTML admin_address2>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_city><font color=red><blink>*</blink></font></TMPL_IF> City:</b></td>
    <td><input type=text name=admin_city value="<TMPL_VAR ESCAPE=HTML admin_city>" size=20></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_state><font color=red><blink>*</blink></font></TMPL_IF> Province:</b></a></td>
    <td><input type=text name=admin_state value="<TMPL_VAR ESCAPE=HTML admin_state>" size=20><br>
        <font size=-1><i>Please use two letter acronym for <a href="help.cgi?tld=ca&topic=province_list" target=help>canadian provinces</a></i>
    </td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_country><font color=red><blink>*</blink></font></TMPL_IF> Country:</b></td>
    <td><select name="admin_country"><TMPL_VAR admin_country_list></select></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_postal_code><font color=red><blink>*</blink></font></TMPL_IF> Postal Code:</b></td>
    <td><input type=text name=admin_postal_code value="<TMPL_VAR ESCAPE=HTML admin_postal_code>" size=8></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_phone><font color=red><blink>*</blink></font></TMPL_IF> Phone:</b></td>
    <td><input type=text name=admin_phone value="<TMPL_VAR ESCAPE=HTML admin_phone>" size=20></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><font size=-1 font color=red>*optional* </font><b>Fax:</b></td>
    <td><input type=text name=admin_fax value="<TMPL_VAR ESCAPE=HTML admin_fax>" size=20></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_admin_email><font color=red><blink>*</blink></font></TMPL_IF> Email:</b></b><br>
     <font size=-1 font color=red>must be a valid email address </font>
    </td>
    <td><input type=text name=admin_email value="<TMPL_VAR ESCAPE=HTML admin_email>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b>Registrant would like to become a CIRA member?:</b></td>
    <td>
     <TMPL_IF cira_member>
      <input type=radio name=cira_member value=1 checked> Yes
      <input type=radio name=cira_member value=0> No
     <TMPL_ELSE>
      <input type=radio name=cira_member value=1> Yes
      <input type=radio name=cira_member value=0 checked> No
     </TMPL_IF>
    </td>
  </tr>


<TMPL_IF custom_tech>

  <tr bgcolor=#90c0ff>
    <th align=center colspan=2><font size=+1>Technical Contact Information</font></th><br>
  </tr>

  <tr bgcolor=#90c0ff>
    <th align=left colspan=2>Admin Contact is also the Technical Contact? &nbsp;&nbsp;
      <input type=radio name=tec_as_admin value="1" <TMPL_IF tec_as_admin>checked</TMPL_IF> > Yes&nbsp;&nbsp;
      <input type=radio name=tec_as_admin value="0" <TMPL_UNLESS tec_as_admin>checked</TMPL_UNLESS>> No
    </th>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right width="20%"><b><TMPL_IF error_tech_first_name><font color=red><blink>*</blink></font></TMPL_IF> First Name:</b></td>
    <td><input type=text name=tech_first_name value="<TMPL_VAR ESCAPE=HTML tech_first_name>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_last_name><font color=red><blink>*</blink></font></TMPL_IF> Last Name:</b></td>
    <td><input type=text name=tech_last_name value="<TMPL_VAR ESCAPE=HTML tech_last_name>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_pref_language><font color=red><blink>*</blink></font></TMPL_IF> Preferred Language:</b></td>
    <td><select name=tech_pref_language size=1>
      <TMPL_IF tech_pref_language><option value='<TMPL_VAR tech_pref_language>' selected><TMPL_VAR tech_lang_long></TMPL_IF> 
      <option value="">Choose One
      <option value="EN">English
      <option value="FR">Français
      </select>
    </td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_org_name><font color=red><blink>*</blink></font></TMPL_IF> Organization Name:</b></td>
    <td><input type=text name=tech_org_name value="<TMPL_VAR ESCAPE=HTML tech_org_name>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_address1><font color=red><blink>*</blink></font></TMPL_IF> Street:</b></td>
    <td><input type=text name=tech_address1 value="<TMPL_VAR ESCAPE=HTML tech_address1>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><font size=-1 font color=red>*optional* </font><b>&nbsp</b></td>
    <td><input type=text name=tech_address2 value="<TMPL_VAR ESCAPE=HTML tech_address2>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_city><font color=red><blink>*</blink></font></TMPL_IF> City:</b></td>
    <td><input type=text name=tech_city value="<TMPL_VAR ESCAPE=HTML tech_city>" size=20></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_state><font color=red><blink>*</blink></font></TMPL_IF> Province:</b></td>
    <td><input type=text name=tech_state value="<TMPL_VAR ESCAPE=HTML tech_state>" size=20><br>
     <font size=-1><i>Please use two letter acronym for <a href="help.cgi?tld=ca&topic=province_list" target=help>canadian provinces</a></i>
    </td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_country><font color=red><blink>*</blink></font></TMPL_IF> Country:</b></td>
    <td><select name="tech_country"><TMPL_VAR tech_country_list></select></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_postal_code><font color=red><blink>*</blink></font></TMPL_IF> Postal Code:</b></td>
    <td><input type=text name=tech_postal_code value="<TMPL_VAR ESCAPE=HTML tech_postal_code>" size=8></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_phone><font color=red><blink>*</blink></font></TMPL_IF> Phone:</b></td>
    <td><input type=text name=tech_phone value="<TMPL_VAR ESCAPE=HTML tech_phone>" size=20></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b>Fax:</b></td>
    <td><input type=text name=tech_fax value="<TMPL_VAR ESCAPE=HTML tech_fax>" size=20></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_tech_email><font color=red><blink>*</blink></font></TMPL_IF> Email:</b></b><br>
     <font size=-1 font color=red>must be a valid email address </font>
    </td>
    <td><input type=text name=tech_email value="<TMPL_VAR ESCAPE=HTML tech_email>" size=30></td>
  </tr>

<br>
</TMPL_IF>

<TMPL_IF custom_dns>

  <tr bgcolor=#90c0ff>
    <th align=center colspan=2><font size=+1>DNS Information</font></th>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right width='20%'><b><TMPL_IF error_fqdn1><font color=red><blink>*</blink></font></TMPL_IF> First DNS Hostname:</b></td>
    <td><input type=text name=fqdn1 value="<TMPL_VAR ESCAPE=HTML fqdn1>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><b><TMPL_IF error_fqdn2><font color=red><blink>*</blink></font></TMPL_IF> Second DNS Hostname:</b></td>
    <td><input type=text name=fqdn2 value="<TMPL_VAR ESCAPE=HTML fqdn2>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><font size=-1 font color=red>*optional* </font><b>Third DNS Hostname:</b></td>
    <td><input type=text name=fqdn3 value="<TMPL_VAR ESCAPE=HTML fqdn3>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><font size=-1 font color=red>*optional* </font><b>Fourth DNS Hostname:</b></td>
    <td><input type=text name=fqdn4 value="<TMPL_VAR ESCAPE=HTML fqdn4>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><font size=-1 font color=red>*optional* </font><b>Fifth DNS Hostname:</b></td>
    <td><input type=text name=fqdn5 value="<TMPL_VAR ESCAPE=HTML fqdn5>" size=30></td>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right><font size=-1 font color=red>*optional* </font><b>Sixth DNS Hostname:</b></td>
    <td><input type=text name=fqdn6 value="<TMPL_VAR ESCAPE=HTML fqdn6>" size=30></td>
  </tr>

<br>
</TMPL_IF>

  <tr bgcolor=#90c0ff>
    <th align=center colspan=2><font size=+1>Domain Name Security</font></th>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=left colspan=2><font size=-1 font color="blue"><i>A domain must be part of an OpenSRS profile. You may add this
      domain to an existing profile. Alternatively, if you do not already have an
      OpenSRS profile you may create a new one. Creating a new profile is easy.</font></i><br><br>
      <input type=radio name=existing_profile value="1" <TMPL_IF existing_profile>checked</TMPL_IF>>  <b>Add</b> this domain to an existing OpenSRS profile <br>
      <input type=radio name=existing_profile value="0" <TMPL_UNLESS existing_profile>checked</TMPL_UNLESS>> <b>Create</b> a new OpenSRS profile for this domain
    </td>
  </tr>
  <tr>
    <td colspan=2>
    <table cellspacing=0 cellpadding=2 width=100%>
      <tr>
        <td align=left>
          <input type=submit value=" Next ">
        </td>
        <td align=right>
          <input type="hidden" name="action" value="setup_profile">
          <input type=submit name="back" value=" Back ">&nbsp;
        </td>
      </tr>
    </table>
    </td>
  </tr>

</table>

</td></tr>
</table>


<TMPL_INCLUDE footer.html>
