mirror of
https://github.com/mozilla/gecko-dev.git
synced 2024-10-13 13:25:37 +00:00
433 lines
13 KiB
HTML
433 lines
13 KiB
HTML
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 3.2//EN">
|
|
<html>
|
|
<body bgcolor="ffffff" text="000000" link="FF0000" alink="FFCC00"
|
|
vlink="FF0000">
|
|
<form>
|
|
<table width="440" cellpadding="0" cellspacing="0" border=
|
|
"0">
|
|
<tr>
|
|
<td>
|
|
<br>
|
|
<table width="400" cellspacing="0" cellpadding="0"
|
|
border="0">
|
|
<tr>
|
|
<td></td>
|
|
<td><input type="RADIO" value="Mr." name=
|
|
"/atg/bmg/enroll/EnrollNameEditor.salutation">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/EnrollNameEditor.salutation"
|
|
value=" ">Mr.
|
|
<input type="RADIO" value="Mrs."
|
|
name="/atg/bmg/enroll/EnrollNameEditor.salutation">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/EnrollNameEditor.salutation"
|
|
value=" ">Mrs.
|
|
<input type="RADIO" value="Ms." name=
|
|
"/atg/bmg/enroll/EnrollNameEditor.salutation">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/EnrollNameEditor.salutation"
|
|
value=" ">Ms.<br>
|
|
<br>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="top">
|
|
First Name:</td>
|
|
|
|
<td align="left" valign="top"><input type="TEXT"
|
|
size="35" value="" name=
|
|
"Name.First"><input
|
|
type="hidden" name=
|
|
"_D:/atg/bmg/enroll/EnrollNameEditor.firstName"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
Middle Initial:</td>
|
|
|
|
<td align="left" valign="middle"><input type="TEXT"
|
|
size="5" value="" name=
|
|
"Name.Middle">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/EnrollNameEditor.middleName"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
Last Name:</td>
|
|
|
|
<td align="left" valign="middle"><input type="TEXT"
|
|
size="35" value="" name=
|
|
"Name.Last"><input
|
|
type="hidden" name=
|
|
"_D:/atg/bmg/enroll/EnrollNameEditor.lastName"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
Email address:</td>
|
|
|
|
<td align="left" valign="middle"><input type="TEXT"
|
|
size="35" maxlength="255" value="" name=
|
|
"Home.Email">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/common/EmailAddressEditor.emailAddress"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
Phone (optional):</td>
|
|
|
|
<td align="left" valign="middle">
|
|
<table border="0" cellpadding="1" cellspacing=
|
|
"0">
|
|
<tr>
|
|
<td valign="middle">(<input type="TEXT" size=
|
|
"3" maxlength="3" value="" name=
|
|
"Home.Phone.LocCode">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/USCustomerAddressEditor.areaCode"
|
|
value=" ">)</td>
|
|
|
|
<td>-<br>
|
|
</td>
|
|
|
|
<td><input type="TEXT" size="3" maxlength="3"
|
|
value="" name=
|
|
"Home.Phone.Number.Prefix">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/USCustomerAddressEditor.phone1"
|
|
value=" "> </td>
|
|
|
|
<td><input type="TEXT" size="4" maxlength="4"
|
|
value="" name=
|
|
"Home.Phone.Number.Suffix">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/USCustomerAddressEditor.phone2"
|
|
value=" "> </td>
|
|
</tr>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="2"> <br>
|
|
<br>
|
|
<hr> <br>
|
|
<br>
|
|
</td>
|
|
</tr>
|
|
<!--ADDRESS-->
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
Street Address:</td>
|
|
|
|
<td align="left" valign="middle"><input type="TEXT"
|
|
size="40" maxlength="40" value="" name=
|
|
"Home.Street.Line1">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/USCustomerAddressEditor.address1"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="2"></td>
|
|
<!--SPACER-->
|
|
</tr>
|
|
<!--
|
|
<tr>
|
|
<td align=right valign=middle>
|
|
Apartment:
|
|
</td>
|
|
<td align=left valign=middle>
|
|
<INPUT TYPE="TEXT" PROPERTY="USCustomerAddressEditor.address2" SIZE="5" maxlength=40>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr><td colspan=2></td>
|
|
</tr>
|
|
-->
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
City:</td>
|
|
|
|
<td align="left" valign="middle"><input type="TEXT"
|
|
size="35" maxlength="30" value="" name=
|
|
"Home.City">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/USCustomerAddressEditor.city"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="2"></td>
|
|
<!--SPACER-->
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
State:</td>
|
|
|
|
<td align="left" valign="middle"><input type="TEXT"
|
|
size="2" maxlength="2" value="" name=
|
|
"Home.State">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/USCustomerAddressEditor.state"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="2"></td>
|
|
<!--SPACER-->
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
Zip Code:</td>
|
|
|
|
<td align="left" valign="middle"><input type="TEXT"
|
|
size="5" maxlength="5" value="" name=
|
|
"Home.PostalCode.Prefix">
|
|
<input type="hidden" name=
|
|
"_D:/atg/bmg/enroll/USCustomerAddressEditor.postalCode"
|
|
value=" "> </td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="2"></td>
|
|
<!--SPACER-->
|
|
</tr>
|
|
|
|
<tr>
|
|
<td align="right" valign="middle">
|
|
Country:</td>
|
|
|
|
<td align="left" valign="middle">
|
|
USA</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="2"> <br>
|
|
<br>
|
|
<hr> <br>
|
|
<br>
|
|
</td>
|
|
</tr>
|
|
<!-- Expects a table wrapper -->
|
|
|
|
<tr valign="top">
|
|
<td>Payment<br>
|
|
Method for<br>
|
|
Shipping and<br>
|
|
Handling<br>
|
|
Charges</td>
|
|
|
|
<td><input type="radio" value="bill" name=
|
|
"/atg/bmg/common/PaymentEditor.paymentType"><input
|
|
type="hidden" name=
|
|
"_D:/atg/bmg/common/PaymentEditor.paymentType"
|
|
value=" ">Bill Me Later<br>
|
|
<br>
|
|
<input type="radio" value="cc" name=
|
|
"/atg/bmg/common/PaymentEditor.paymentType"><input
|
|
type="hidden" name=
|
|
"_D:/atg/bmg/common/PaymentEditor.paymentType"
|
|
value=" ">Use Credit Card<br>
|
|
<br>
|
|
Card type:<br>
|
|
<select name=
|
|
"Card.Type">
|
|
<option value="">
|
|
</option>
|
|
|
|
<option value="Visa">
|
|
Visa
|
|
</option>
|
|
|
|
<option value="MasterCard">
|
|
MasterCard
|
|
</option>
|
|
|
|
<option value="American Express">
|
|
American Express
|
|
</option>
|
|
|
|
<option value="Discover">
|
|
Discover
|
|
</option>
|
|
</select><input type="hidden" name=
|
|
"_D:/atg/bmg/common/PaymentEditor.ccType" value=
|
|
" "> <br>
|
|
<br>
|
|
Card Number:<br>
|
|
<input type="text" size="35" value="" name=
|
|
"Card.Number"><input
|
|
type="hidden" name=
|
|
"_D:/atg/bmg/common/PaymentEditor.ccNumber" value=
|
|
" "> <br>
|
|
<br>
|
|
Expiration date:<br>
|
|
<select name=
|
|
"Card.ExpDate.Month">
|
|
<option value="">
|
|
</option>
|
|
|
|
<option value="0">
|
|
Jan
|
|
</option>
|
|
|
|
<option value="1">
|
|
Feb
|
|
</option>
|
|
|
|
<option value="2">
|
|
Mar
|
|
</option>
|
|
|
|
<option value="3">
|
|
Apr
|
|
</option>
|
|
|
|
<option value="4">
|
|
May
|
|
</option>
|
|
|
|
<option value="5">
|
|
Jun
|
|
</option>
|
|
|
|
<option value="6">
|
|
Jul
|
|
</option>
|
|
|
|
<option value="7">
|
|
Aug
|
|
</option>
|
|
|
|
<option value="8">
|
|
Sep
|
|
</option>
|
|
|
|
<option value="9">
|
|
Oct
|
|
</option>
|
|
|
|
<option value="10">
|
|
Nov
|
|
</option>
|
|
|
|
<option value="11">
|
|
Dec
|
|
</option>
|
|
</select><input type="hidden" name=
|
|
"_D:/atg/bmg/common/PaymentEditor.ccExpirationMonth"
|
|
value=" "> <select name=
|
|
"Card.ExpDate.Year">
|
|
<option value="">
|
|
</option>
|
|
|
|
<option value="1997">
|
|
1997
|
|
</option>
|
|
|
|
<option value="1998">
|
|
1998
|
|
</option>
|
|
|
|
<option value="1999">
|
|
1999
|
|
</option>
|
|
|
|
<option value="2000">
|
|
2000
|
|
</option>
|
|
|
|
<option value="2001">
|
|
2001
|
|
</option>
|
|
|
|
<option value="2002">
|
|
2002
|
|
</option>
|
|
|
|
<option value="2003">
|
|
2003
|
|
</option>
|
|
|
|
<option value="2004">
|
|
2004
|
|
</option>
|
|
|
|
<option value="2005">
|
|
2005
|
|
</option>
|
|
|
|
<option value="2006">
|
|
2006
|
|
</option>
|
|
|
|
<option value="2007">
|
|
2007
|
|
</option>
|
|
|
|
<option value="2008">
|
|
2008
|
|
</option>
|
|
|
|
<option value="2009">
|
|
2009
|
|
</option>
|
|
|
|
<option value="2010">
|
|
2010
|
|
</option>
|
|
</select><input type="hidden" name=
|
|
"_D:/atg/bmg/common/PaymentEditor.ccExpirationYear"
|
|
value=" "><br>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="2"> <br>
|
|
<br>
|
|
<hr> <br>
|
|
<br>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<input type="submit" value="submit">
|
|
</form>
|
|
<br>
|
|
<br>
|
|
</body>
|
|
</html>
|
|
|