<TMPL_INCLUDE header.html>

<table border=1>
<tr><td>

<table border=0 width=550>
  <tr bgcolor=#90c0ff>
    <th align=center colspan=2><font size=+1>Domain Information</font></th>
  </tr>

  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Domain Name:</b></td>
    <td><TMPL_VAR domain></td>
  </tr>
  
  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Registration Period</b></td>
    <td><TMPL_VAR period> Year(s)</td>
  </tr>
  
  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Is this domain a registered trademark?</b></td>
    <td><TMPL_IF isa_trademark>Yes<TMPL_ELSE>No</TMPL_IF></td>
  </tr>

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

<TMPL_IF RANT_NO>
  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Registrant Number:</b></td>
    <td><TMPL_VAR rant_no></td>
  </tr>
  
  <tr bgcolor=#e0e0e0>
    <td align=center colspan=2>The admin contact of registrant id <TMPL_VAR rant_no> will be contacted to approve this request</td>
  </tr>
  
<TMPL_ELSE>
 
<TMPL_IF CA_LINK_DOMAIN>

  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Registrant:</b></td>
    <td>Owner of <TMPL_VAR reg_domain></td>
  </tr>

 <TMPL_ELSE>
 
  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Registrant Name:</b></td>
    <td><TMPL_VAR reg_name></td>
  </tr>

<TMPL_IF reg_desc>

  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Registrant Description</b></td>
    <td><TMPL_VAR escape=html reg_desc></td>
  </tr>
</TMPL_IF>
  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Legal Type:</b></td>
    <td><TMPL_VAR legal_type></td>
  </tr>
</TMPL_IF>
</TMPL_IF>

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

 <TMPL_IF existing_profile>

  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>Existing OpenSRS profile:</b></td>
    <td><TMPL_VAR reg_domain>/<TMPL_VAR escape=html reg_username></td>
  </tr>

 <TMPL_ELSE>
 
  <tr bgcolor=#e0e0e0>
    <td align=right width='35%'><b>New OpenSRS profile:</b></td>
    <td><TMPL_VAR escape=html reg_username></td>
  </tr>
  
 </TMPL_IF>

  <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>First Name:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_first_name></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Last Name:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_last_name></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Preferred Language:</b></td>
<td><TMPL_VAR admin_pref_language></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Organization Name:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_org_name></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Street:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_address1></td>
</tr>
<tr bgcolor=#e0e0e0>
<td align=right><b>&nbsp</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_address2>&nbsp;</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>City:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_city></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Province:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_state></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Country:</b></td>
<td><TMPL_VAR admin_country></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Postal Code:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_postal_code></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Phone:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_phone></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Fax:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_fax>&nbsp;</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Email:</b></td>
<td><TMPL_VAR ESCAPE=HTML admin_email></td>
</tr>

</table>

<br>
<TMPL_IF custom_tech>
<table border=0 cellspacing=1 cellpadding=3 width=100%>
<tr bgcolor=#90c0ff>
<th align=center colspan=2><font size=+1>Technical Contact Information</font><br>
<TMPL_IF tec_as_admin>Admin Contact is also the Technical Contact</TMPL_IF>
</th>
</tr>
<TMPL_UNLESS tec_as_admin>
<tr bgcolor=#e0e0e0>
<td align=right width="35%"><b>First Name:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_first_name></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Last Name:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_last_name></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Preferred Language:</b></td>
<td><TMPL_VAR tech_pref_language>
</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Organization Name:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_org_name></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Street:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_address1></td>
</tr>
<tr bgcolor=#e0e0e0>
<td align=right><b>&nbsp;</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_address2>&nbsp;</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>City:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_city></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Province:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_state><br>
</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Country:</b></td>
<td><TMPL_VAR tech_country>
</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Postal Code:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_postal_code></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Phone:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_phone></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Fax:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_fax>&nbsp;</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Email:</b></td>
<td><TMPL_VAR ESCAPE=HTML tech_email></td>
</tr>
</TMPL_UNLESS>
</table>

<br>
</TMPL_IF>
<TMPL_IF custom_dns>
<table border=0 cellspacing=1 cellpadding=3 width=100%>
<tr bgcolor=#90c0ff>
    <th align=center colspan=2><font size=+1>DNS Information</font></th>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right width='35%'><b>First DNS Hostname:</b></td>
<td><TMPL_VAR ESCAPE=HTML fqdn1></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Second DNS Hostname:</b></td>
<td><TMPL_VAR ESCAPE=HTML fqdn2></td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Third DNS Hostname:</b></td>
<td><TMPL_VAR ESCAPE=HTML fqdn3>&nbsp;</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Fourth DNS Hostname:</b></td>
<td><TMPL_VAR ESCAPE=HTML fqdn4>&nbsp;</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Fifth DNS Hostname:</b></td>
<td><TMPL_VAR ESCAPE=HTML fqdn5>&nbsp;</td>
</tr>

<tr bgcolor=#e0e0e0>
<td align=right><b>Sixth DNS Hostname:</b></td>
<td><TMPL_VAR ESCAPE=HTML fqdn6>&nbsp;</td>
</tr>

</table>

<br>
</TMPL_IF>
<TMPL_IF show_cc_fields>
<table border=0 cellspacing=1 cellpadding=3 width=100%>
<tr bgcolor=#90c0ff>
<th align=center colspan=2><font size=+1>Credit Card Information</font>
</th>
</tr>
<tr bgcolor=#e0e0e0>
<td align=right width="35%"><b>Card Type:</b></td>
<td><TMPL_VAR ESCAPE=HTML p_cc_type></td>
</tr>
<tr bgcolor=#e0e0e0>
<td align=right width="35%"><b>Card Number:</b></td>
<td><TMPL_VAR ESCAPE=HTML p_cc_num></td>
</tr>
<tr bgcolor=#e0e0e0>
<td align=right width="35%"><b>Expiration:</b></td>
<td><TMPL_VAR ESCAPE=HTML p_cc_exp_month>/<TMPL_VAR ESCAPE=HTML p_cc_exp_year></td>
</tr>
</table>
</TMPL_IF>

<table cellspacing=0 cellpadding=2 width=100%>
<tr>
<td align=left>
    <input type="hidden" name="action" value="submit_order">
    <input type=submit name="back" value=" Back ">&nbsp;
</td>
<td align=right>
    
    <input type=submit value=" Submit Order ">
</td>
</tr>
</table>

</td>
</tr>
</table>
<TMPL_INCLUDE footer.html>
