<center>
<font size=+2><b>Registration Verification</b></font>
</center>
<blockquote><blockquote><font size=+1 color=blue>
One More Step...</font><BR>
Please verify that the information submitted is correct.  If everything looks good, hit the <B>"Order Now!"</b> button to complete the process.
</blockquote></blockquote>
<center>
<form method=post action="{{CGI}}">
<input type=submit value="Order Now!"><BR><BR>
<table border=4 cellpadding=5 cellspacing=0>
<TR><TD colspan=2 align=center><B>Registration Type: <font color=red>{{reg_type_text}}</font></b></td></tr>

<tr>
<td colspan=2><center><b>Domains:</b></center>
<br>
{{bad_domains}}
<b>Valid Domains:</b><br>
{{domains}}
</td>
</tr>

<tr>
<td align=right><b>Registration Period:</b></td>
<td>{{period_text}}</td>
</tr>

{{auto_renew_section}}
{{domain_locking_section}}

<TR><TD colspan=2 align=center><B>.US Nexus Information</b></td></tr>
<tr><td colspan=2>
Application Purpose: {{app_purpose}}<BR>
Nexus Category: {{nexus_category}}<BR>
Country of Citizenship: {{nexus_validator}}<BR>
</td></tr>

<TR><TD colspan=2 align=center><B>Main Contact Information</b></td></tr>
<tr><td valign=top>
{{owner_first_name}} {{owner_last_name}}<BR>
{{owner_org_name}}<BR>
{{owner_address1}}<BR>
{{owner_address2}}
{{owner_address3}}
{{owner_city}}, {{owner_state}} {{owner_postal_code}}<BR>
{{owner_country}}
</td><td valign=top>
Phone:{{owner_phone}}<BR>
Fax:{{owner_fax}}<BR>
E-mail:{{owner_email}}<BR>
</td></tr>
{{VERIFY_CC_FIELDS}}
<tr><td colspan=2 align=center><b>Admin Information</b></td></tr>
<tr><td valign=top>
{{admin_first_name}} {{admin_last_name}}<BR>
{{admin_org_name}}<BR>
{{admin_address1}}<BR>
{{admin_address2}}
{{admin_address3}}
{{admin_city}}, {{admin_state}} {{admin_postal_code}}<BR>
{{admin_country}}
</td><td valign=top>
Phone:{{admin_phone}}<BR>
Fax:{{admin_fax}}<BR>
E-mail:{{admin_email}}<BR>
</td></tr>


<tr><td colspan=2 align=center><b>Billing Information</b></td></tr>
<tr><td valign=top>
{{billing_first_name}} {{billing_last_name}}<BR>
{{billing_org_name}}<BR>
{{billing_address1}}<BR>
{{billing_address2}}
{{billing_address3}}
{{billing_city}}, {{billing_state}} {{billing_postal_code}}<BR>
{{billing_country}}
</td><td valign=top>
Phone:{{billing_phone}}<BR>
Fax:{{billing_fax}}<BR>
E-mail:{{billing_email}}<BR>
</td></tr>

{{TECH_CONTACT}}

{{NAMESERVERS}}

</table>

<BR>
<input type=hidden name=affiliate_id value="{{affiliate_id}}">

<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}}">
<input type=hidden name=period value="{{period}}">

{{domain_string}}

{{SPECIAL_DOMAIN_INFO}}
{{CONTACT_INFO}}
{{NAMESERVER_INFO}}
{{BILLING_INFO}}
<input type=submit value="Order Now!">
<input type=hidden name=action value="{{action}}">
<input type=hidden name=mldn value="{{mldn}}">
</form>
</center>
<BR><BR>
