<div>
    <div id="kb" class="block">
        <div class="block_title">
            <h3><b><a href="#">[l]Support Center[/l]</a> &raquo; <a href="#">[l]Order Enom Account[/l]</a></b></h3>
        </div>
        <ul>
            <li>
                <div style="margin:8px;">
                {SNAPIN_HEADER}
                </div>
            </li>
            <li>
                <div align="center" style="color:red">{ERR}</div>
                <form method='post' id="submit_ticket" action='index.php?fuse=admin&amp;view=Snapins&amp;plugin=enomform&amp;public=1'>
                    <fieldset>
                        <legend>[l]Enom Account Registration Form[/l]</legend>
                        <div class="razmak">
                            <span class="label130">[l]Organization[/l] :</span>
                            <input type="text" name="org" id="org" value="{ORGANIZATION}" />
                            <br />
                            <span class="label130">[l]Account Type[/l] :</span>
                            <select name="accounttype" id="accounttype">
                                <option value="1">Reseller Account</option>
                                <option value="0" {RETAIL}>Retail Account</option>
                            </select>
                            <br />
                            <span class="label130">[l]Title[/l] :</span>
                            <input type="text" name="title" id="title" value="{TITLE}" />
                            <br />
                            <span class="label130">[l]First Name[/l] :</span>
                            <input type="text" name="fname" id="fname" value="{FNAME}" />
                            <br />
                            <span class="label130">[l]Last Name[/l] :</span>
                            <input type="text" name="lname" id="lname" value="{LNAME}" />
                            <br />
                            <span class="label130">[l]E-mail[/l] :</span>
                            <input type="text" name="email" id="email" value="{EMAIL}" />
                            <br />
                            <span class="label130">[l]Preferred Username[/l]&nbsp;:</span>
                            <input type="text" name="username" id="username" value="{ID}" />
                            <br />
                            <span class="label130">[l]Password[/l] :</span>
                            <input type="text" name="password" id="password" value="{PW}" />
                            <br />
                            <span class="label130">[l]Confirm Password[/l] :</span>
                            <input type="text" name="password2" id="password2" value="{PW2}" />
                            <br />
                            <span class="label130">[l]Secret Word Type[/l] :</span>
                            <select name="secrettype" id="secrettype">
                                <option value="smaiden">Mother's Maiden Name</option>
                                <option value="sbirth" {COB}>City of Birth</option>
                                <option value="ssocial" {L4D}>Last 4 Digits of Social Security Number</option>
                                <option value="shigh" {HS}>Full Name of High School</option>
                            </select>
                            <br />
                            <span class="label130">[l]Secret Word[/l] :</span>
                            <input type="text" name="sword" id="sword" value="{ANS}" />
                            <br />
                            <span class="label130">[l]Address[/l] :</span>
                            <input type="text" name="address" id="address" value="{ADDRESS}" />
                            <br />
                            <span class="label130">[l]City[/l] :</span>
                            <input type="text" name="city" id="city" value="{CITY}" />
                            <br />
                            <span class="label130">[l]State[/l] :</span>
                            <input type="text" name="state" id="state" value="{STATE}" />
                            <br />
                            <span class="label130">[l]Country[/l] :</span>
                            <input type="text" name="country" id="country" value="{COUNTRY}" />
                            <br />
                            <span class="label130">[l]Zip Code[/l] :</span>
                            <input type="text" name="zip" id="zip" value="{ZIPCODE}" />
                            <br />
                            <span class="label130">[l]Phone[/l] :</span>
                            <input type="text" name="phone" id="phone" value="{PHONE}" />
                            <br />
                            <span class="label130">[l]ClientExec Domain[/l] :</span>
                            <input type="text" name="domain" id="domain" value="" />
                        </div>
                    </fieldset>
                    <div class="st_submit">
                        <input type="submit" name="submit" value='[l]Sign Up[/l]' />
                    </div>
                </form>
            </li>
        </ul>
    </div>
</div>
