<center><Font size=+2><B><font color=red>.CA</font> Domain {{reg_text}} - Order Form</B></FONT></center>

<BLOCKQUOTE>
Congratulations on your decision to move forward with your business 
and register your own <font color=red>.CA</font> 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.
<P>
<I>Please note that by CIRA request, you must have a presence in Canada
in order to qualify for a <font color=red>.CA</font> domain.  This means that at least one
of your contacts must be located in Canada.</I><P>
</BLOCKQUOTE>

<center><FONT color = red><B>{{syntax_error_msg}} </B></FONT></center>
<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>
<TR>
	<TD bgcolor="#e0e0e0" align=right><B>Profile:</B></td>
	<TD>{{reg_profile}}<br>
    <font color=red>NOTE: </font><font size=-1>
    If an existing .ca domain, username and password are included
    in this section, then OpenSRS will ignore registration information
    included in this form, and the name will simply be added to the existing
    Registrant Profile at CIRA.</font>
    </td>
</tr>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Organization Name:</B></TD>
	<TD><input name="owner_org_name" size=39 value="{{owner_org_name}}"></TD>
</TR>

<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Owner Description</B><BR>
	    <I>(max 2000 characters)</I></TD>
	<TD>
	    <textarea name="domain_description" ROWS="6" COLS="50">{{domain_description}}</textarea>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Is this domain a registered trade-mark?</B></TD>
	<TD>
	    <input type="radio" name="isa_trademark" value="0" checked>No&nbsp;
	    <input type="radio" name="isa_trademark" value="1">Yes
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Language Preference:</B></TD>
	<TD>
	    <select name="lang_pref">
		    <option value="EN" selected>English
		    <option value="FR">Francais
	    </select>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Legal Type:</B></TD>
	<TD>
		<select name="legal_type">
			{{ca_legal_type_menu}}
		</select>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#e0e0e0"><B>Become CIRA Member:</B></TD>
	<TD>
	<input type="radio" name="cira_member" checked value="Y"> Yes
	<input type="radio" name="cira_member" value="N"> No
	</TD>
</TR>
</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>Admin 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"><B>City:</B></TD>
	<TD><input name="admin_city" size=15 value="{{admin_city}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Province:</B></TD>
	<TD><input name="admin_state" size=15 value="{{admin_state}}"> 
	    <font size=-1>(If in Canada, please use AB, ON, QC, etc)</font></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Country:</B></TD>
	<TD><SELECT NAME="admin_country">
{{country_menu}}
 </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><BR>
	    <FONT color=red size=-1>Must be currently valid address</FONT>
	</TD>
	<TD><input name="admin_email" size=39 value="{{admin_email}}"></TD>
</TR>

{{CUSTOM_TECH_CONTACT}}

{{CUSTOM_NAMESERVERS}}

</TABLE>

<!--End custom table 2-->


</TD></TR>

{{CC_FIELDS}}

<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>

<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=ca_reg_type value="{{ca_reg_type}}">
<input type=hidden name=old_domain value="{{old_domain}}">
<input type=hidden name=bulk_order value="{{bulk_order}}">
</form>
<BR>
