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433 lines
13 KiB
HTML
433 lines
13 KiB
HTML
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 3.2//EN">
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<html>
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<body bgcolor="ffffff" text="000000" link="FF0000" alink="FFCC00"
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vlink="FF0000">
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<form>
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<table width="440" cellpadding="0" cellspacing="0" border=
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"0">
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<tr>
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<td>
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<br>
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<table width="400" cellspacing="0" cellpadding="0"
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border="0">
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<tr>
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<td></td>
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<td><input type="RADIO" value="Mr." name=
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"/atg/bmg/enroll/EnrollNameEditor.salutation">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/EnrollNameEditor.salutation"
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value=" ">Mr.
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<input type="RADIO" value="Mrs."
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name="/atg/bmg/enroll/EnrollNameEditor.salutation">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/EnrollNameEditor.salutation"
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value=" ">Mrs.
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<input type="RADIO" value="Ms." name=
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"/atg/bmg/enroll/EnrollNameEditor.salutation">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/EnrollNameEditor.salutation"
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value=" ">Ms.<br>
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<br>
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</td>
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</tr>
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<tr>
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<td align="right" valign="top">
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First Name:</td>
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<td align="left" valign="top"><input type="TEXT"
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size="35" value="" name=
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"Name.First"><input
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type="hidden" name=
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"_D:/atg/bmg/enroll/EnrollNameEditor.firstName"
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value=" "> </td>
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</tr>
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<tr>
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<td> </td>
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</tr>
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<tr>
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<td align="right" valign="middle">
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Middle Initial:</td>
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<td align="left" valign="middle"><input type="TEXT"
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size="5" value="" name=
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"Name.Middle">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/EnrollNameEditor.middleName"
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value=" "> </td>
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</tr>
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<tr>
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<td></td>
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</tr>
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<tr>
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<td align="right" valign="middle">
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Last Name:</td>
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<td align="left" valign="middle"><input type="TEXT"
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size="35" value="" name=
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"Name.Last"><input
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type="hidden" name=
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"_D:/atg/bmg/enroll/EnrollNameEditor.lastName"
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value=" "> </td>
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</tr>
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<tr>
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<td></td>
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</tr>
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<tr>
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<td align="right" valign="middle">
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Email address:</td>
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<td align="left" valign="middle"><input type="TEXT"
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size="35" maxlength="255" value="" name=
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"Home.Email">
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<input type="hidden" name=
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"_D:/atg/bmg/common/EmailAddressEditor.emailAddress"
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value=" "> </td>
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</tr>
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<tr>
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<td> </td>
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</tr>
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<tr>
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<td align="right" valign="middle">
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Phone (optional):</td>
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<td align="left" valign="middle">
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<table border="0" cellpadding="1" cellspacing=
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"0">
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<tr>
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<td valign="middle">(<input type="TEXT" size=
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"3" maxlength="3" value="" name=
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"Home.Phone.LocCode">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/USCustomerAddressEditor.areaCode"
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value=" ">)</td>
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<td>-<br>
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</td>
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<td><input type="TEXT" size="3" maxlength="3"
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value="" name=
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"Home.Phone.Number.Prefix">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/USCustomerAddressEditor.phone1"
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value=" "> </td>
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<td><input type="TEXT" size="4" maxlength="4"
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value="" name=
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"Home.Phone.Number.Suffix">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/USCustomerAddressEditor.phone2"
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value=" "> </td>
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</tr>
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</table>
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</td>
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</tr>
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<tr>
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<td colspan="2"> <br>
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<br>
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<hr> <br>
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<br>
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</td>
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</tr>
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<!--ADDRESS-->
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<tr>
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<td align="right" valign="middle">
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Street Address:</td>
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<td align="left" valign="middle"><input type="TEXT"
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size="40" maxlength="40" value="" name=
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"Home.Street.Line1">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/USCustomerAddressEditor.address1"
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value=" "> </td>
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</tr>
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<tr>
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<td colspan="2"></td>
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<!--SPACER-->
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</tr>
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<!--
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<tr>
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<td align=right valign=middle>
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Apartment:
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</td>
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<td align=left valign=middle>
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<INPUT TYPE="TEXT" PROPERTY="USCustomerAddressEditor.address2" SIZE="5" maxlength=40>
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</td>
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</tr>
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<tr><td colspan=2></td>
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</tr>
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-->
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<tr>
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<td align="right" valign="middle">
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City:</td>
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<td align="left" valign="middle"><input type="TEXT"
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size="35" maxlength="30" value="" name=
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"Home.City">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/USCustomerAddressEditor.city"
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value=" "> </td>
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</tr>
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<tr>
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<td colspan="2"></td>
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<!--SPACER-->
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</tr>
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<tr>
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<td align="right" valign="middle">
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State:</td>
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<td align="left" valign="middle"><input type="TEXT"
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size="2" maxlength="2" value="" name=
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"Home.State">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/USCustomerAddressEditor.state"
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value=" "> </td>
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</tr>
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<tr>
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<td colspan="2"></td>
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<!--SPACER-->
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</tr>
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<tr>
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<td align="right" valign="middle">
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Zip Code:</td>
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<td align="left" valign="middle"><input type="TEXT"
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size="5" maxlength="5" value="" name=
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"Home.PostalCode.Prefix">
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<input type="hidden" name=
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"_D:/atg/bmg/enroll/USCustomerAddressEditor.postalCode"
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value=" "> </td>
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</tr>
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<tr>
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<td colspan="2"></td>
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<!--SPACER-->
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</tr>
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<tr>
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<td align="right" valign="middle">
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Country:</td>
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<td align="left" valign="middle">
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USA</td>
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</tr>
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<tr>
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<td colspan="2"> <br>
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<br>
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<hr> <br>
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<br>
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</td>
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</tr>
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<!-- Expects a table wrapper -->
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<tr valign="top">
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<td>Payment<br>
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Method for<br>
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Shipping and<br>
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Handling<br>
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Charges</td>
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<td><input type="radio" value="bill" name=
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"/atg/bmg/common/PaymentEditor.paymentType"><input
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type="hidden" name=
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"_D:/atg/bmg/common/PaymentEditor.paymentType"
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value=" ">Bill Me Later<br>
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<br>
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<input type="radio" value="cc" name=
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"/atg/bmg/common/PaymentEditor.paymentType"><input
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type="hidden" name=
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"_D:/atg/bmg/common/PaymentEditor.paymentType"
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value=" ">Use Credit Card<br>
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<br>
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Card type:<br>
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<select name=
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"Card.Type">
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<option value="">
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</option>
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<option value="Visa">
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Visa
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</option>
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<option value="MasterCard">
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MasterCard
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</option>
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<option value="American Express">
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American Express
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</option>
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<option value="Discover">
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Discover
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</option>
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</select><input type="hidden" name=
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"_D:/atg/bmg/common/PaymentEditor.ccType" value=
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" "> <br>
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<br>
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Card Number:<br>
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<input type="text" size="35" value="" name=
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"Card.Number"><input
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type="hidden" name=
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"_D:/atg/bmg/common/PaymentEditor.ccNumber" value=
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" "> <br>
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<br>
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Expiration date:<br>
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<select name=
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"Card.ExpDate.Month">
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<option value="">
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</option>
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<option value="0">
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Jan
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</option>
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<option value="1">
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Feb
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</option>
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<option value="2">
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Mar
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</option>
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<option value="3">
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Apr
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</option>
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<option value="4">
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May
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</option>
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<option value="5">
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Jun
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</option>
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<option value="6">
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Jul
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</option>
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<option value="7">
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Aug
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</option>
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<option value="8">
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Sep
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</option>
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<option value="9">
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Oct
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</option>
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<option value="10">
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Nov
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</option>
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<option value="11">
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Dec
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</option>
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</select><input type="hidden" name=
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"_D:/atg/bmg/common/PaymentEditor.ccExpirationMonth"
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value=" "> <select name=
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"Card.ExpDate.Year">
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<option value="">
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</option>
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<option value="1997">
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1997
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</option>
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<option value="1998">
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1998
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</option>
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<option value="1999">
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1999
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</option>
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<option value="2000">
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2000
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</option>
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<option value="2001">
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2001
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</option>
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<option value="2002">
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2002
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</option>
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<option value="2003">
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2003
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</option>
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<option value="2004">
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2004
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</option>
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<option value="2005">
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2005
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</option>
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<option value="2006">
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2006
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</option>
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<option value="2007">
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2007
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</option>
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<option value="2008">
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2008
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</option>
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<option value="2009">
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2009
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</option>
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<option value="2010">
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2010
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</option>
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</select><input type="hidden" name=
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"_D:/atg/bmg/common/PaymentEditor.ccExpirationYear"
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value=" "><br>
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</td>
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</tr>
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<tr>
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<td colspan="2"> <br>
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<br>
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<hr> <br>
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<br>
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</td>
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</tr>
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</table>
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</td>
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</tr>
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</table>
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<input type="submit" value="submit">
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</form>
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<br>
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<br>
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</body>
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</html>
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