<center><Font size=+2><B>{{heading}} - Order Form</B></FONT></center>

<BLOCKQUOTE>
Congratulations on your decision to move forward with your business 
and register your own 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.
Please note that Bulk registration of IDN (Internationalized Domain Name - 
Non-ASCII) domain names cannot be processed using this interface. 
Any non ASCII based submissions will return an error.
</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 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=" R E S E T "></th>
      </tr>
</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 bgcolor="e0e0e0">
    <TD align=right>
        <B>Domains:</B>
    </TD>
    <TD>
        <textarea name=domains cols=20 rows=5>{{domains}}</textarea>
    </TD>
</TR>
<TR>
        <TD align=right bgcolor="#e0e0e0"><b>Registration Period:</b></td>
        <TD><select name=period>
            {{PERIOD_LIST}}
            </select>
            <i>(2 years for .uk, max 5 years for .cn)</i><br>
        </TD>
</TR>
{{AUTO_RENEW}}
<TR>
	<TD bgcolor="#e0e0e0" align=right><B>Profile:</B></td>
	<TD>{{reg_profile}}</td>
</tr>
</TABLE>

<!--End First custom table-->

</TD></TR>
<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>Owner Contact Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>First Name:</B></TD>
	<TD><input name="owner_first_name" size=15 value="{{owner_first_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Last Name:</B></TD>
	<TD><input name="owner_last_name" size=15 value="{{owner_last_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Organization Name:</B></TD>
	<TD><input name="owner_org_name" size=39 value="{{owner_org_name}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Street Address:</B></TD>
	<TD><input name="owner_address1" size=39 value="{{owner_address1}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>(eg: Suite #245):</B></TD>
	<TD><input name="owner_address2" size=39 value="{{owner_address2}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><font color=red size=-1>
                *optional*</font> <B>Address 3:</B></TD>
	<TD><input name="owner_address3" size=39 value="{{owner_address3}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>City:</B></TD>
	<TD><input name="owner_city" size=15 value="{{owner_city}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>State:</B></TD>
	<TD><input name="owner_state" size=15 value="{{owner_state}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Country:</B></TD>
	<TD><SELECT NAME="owner_country">
{{country_menu}}
 </SELECT></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Postal Code:</B></TD>
	<TD><input name="owner_postal_code" size=15 value="{{owner_postal_code}}"></TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><B>Phone Number:</B></TD>
	<TD><input name="owner_phone" size=40 value="{{owner_phone}}">
	    <font size=-1><br>(eg. +1.4165551122x1234 for .info/.biz/.us/.name/.cn/.org/.asia domains)</font>
	</TD>
</TR>
<TR>
	<TD ALIGN=right bgcolor="#90c0ff"><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. +1.4165551122x1234 for .info/.biz/.us/.name/.cn/.org/.asia domains)</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="owner_email" size=39 value="{{owner_email}}"></TD>
</TR>
<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Admin Contact Information</FONT></B>
	</TD>
</TR>
<TR>
	<TD COLSPAN=2 bgcolor="e0e0e0" align=center>
		<B>Same as Owner Information</B> <input type=checkbox name=flag_admin_use_contact_info value=1><br>
	</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>(eg: Suite #245):</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>Country:</B></TD>
	<TD><SELECT NAME="admin_country">
{{admin_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. +1.4165551122x1234 for .info/.biz/.us/.name/.cn/.org/.asia domains)</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. +1.4165551122x1234 for .info/.biz/.us/.name/.cn/.org/.asia domains)</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>
<TR>
	<TD COLSPAN=2 bgcolor="#90c0ff" align=center>
		<B><FONT SIZE=+1>Billing Contact Information</FONT></B>
	</TD>
</TR>

<TR>
	<TD COLSPAN=2 bgcolor="e0e0e0" align=center>
		<B>Same as Owner Information</B> <input type=checkbox name=flag_billing_use_contact_info value=1><br>
		<B>Same as Admin Information</B> <input type=checkbox name=flag_billing_use_admin_info value=1><br>
		<font color=red size=-1>If both checkboxes are selected, 'Owner Information' checkbox will be default.</font><br>
	</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>(eg: Suite #245):</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>Country:</B></TD>
	<TD><SELECT NAME="billing_country">
{{billing_country_menu}}
 </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. +1.4165551122x1234 for .info/.biz/.us/.name/.cn/.org/.asia domains)</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. +1.4165551122x1234 for .info/.biz/.us/.name/.cn/.org/.asia domains)</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="billing_email" size=39 value="{{billing_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=" R E S E T "></th>
</tr>
</table>
</TD></TR>

</table>
<BR>
</CENTER>

<br><pre>
* - Phone and fax formats are as follows (extention is optional):
    +{country_dialing_code}.{phone_number}[x{extension}]
    eg. "+44.02055511928"
<pre>

<input type=hidden name=affiliate_id value="{{affiliate_id}}">
<input type=hidden name=action value="verify_order">
<input type=hidden name=bulk_order value="{{bulk_order}}">
<input type=hidden name=reg_type value="{{reg_type}}">
<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}}">
</form>
<BR>
