<div align='center'><b>ClientExec Enom Registration Form</b></div>
<br style="clear: both;">
<div class="yellowbox">
    {SNAPIN_HEADER}
</div>
<br>
<table width='100%' cellpadding=0 border=0 cellspacing=0>
    <tr><td class="snapshot-header-left">
    </td><td class="snapshot-header" nowrap>
    <font class=snapshot-header-text>
    Enom Account Registration Form</font>

    <font class=snapshot-header-description></font></td>
    <td class="snapshot-header" align=right></td>
    <td class="snapshot-header-right"></td></tr>
</table>
<div align="center" style="color:red">{ERR}</div>
<div style="background-color:#f0f6f5; border-bottom:1px solid #b1d6cd; padding-left:10px;"><br style="clear: both;">
<form method='post' action='index.php?fuse=admin&amp;view=Snapins&amp;plugin=enomform'>
<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Organization: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="org" size="30" value="{ORGANIZATION}" />
</span>
<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Account Type: </span></span>
<span style="float: left;width:31%;">
<select name="accounttype"><option value="1">Reseller Account</option><option value="0" {RETAIL}>Retail Account</option></select>
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Title: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="title" size="30" value="{TITLE}"/>
</span>
<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Preferred Username: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="username" size="30" value="{ID}"/>
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>First Name: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="fname" size="30" value="{FNAME}" />
</span>
<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Password: </span></span>
<span style="float: left;width:31%;">
<input type="password" name="password" size="30" value="{PW}"/>
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Last Name: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="lname" size="30" value="{LNAME}" />
</span>
<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Password Confirmation: </span></span>
<span style="float: left;width:31%;">
<input type="password" name="password2" size="30" value="{PW2}"/>
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Email: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="email" size="30" value="{EMAIL}" />
</span>
<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Secret Word Type: </span></span>
<span style="float: left;width:31%;">
<select name="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>
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Address: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="address" size="30" value="{ADDRESS}" />
</span>
<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Secret Word: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="sword" size="30" value="{ANS}" />
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>City: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="city" size="30" value="{CITY}" />
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>State: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="state" size="30" value="{STATE}" />
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Country: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="country" size="30" value="{COUNTRY}" />
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Zip Code: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="zip" size="30" value="{ZIPCODE}" />
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:19%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Phone: </span></span>
<span style="float: left;width:31%;">
<input type="text" name="phone" size="30" value="{PHONE}" />
</span>
<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>
</div>
<div class="clearline"></div>
<div align="right"><input type="submit" class=button_large name="submit" value='Sign Up' /></div>
</form>

