<div>
    <div id="kb" class="block">
        <ul>
            <li>
                <div style="margin:8px;">
                    {SNAPIN_HEADER}
                </div>
            </li>
            <li>
                <!-- BEGIN DYNAMIC BLOCK: signupForm -->
                <div align="center" style="color:red">
                    {ERR}
                </div>
                
                <form method='post' id="submit_ticket" action='index.php?fuse=admin&amp;view=Snapins&amp;plugin=opensrsform&amp;public=1'>
                    <fieldset>
                        <legend>
                            [l]OpenSRS Account Registration Form[/l]
                        </legend>
                        
                        <div class="razmak">
                            <span class="label130">
                                [l]Admin E-mail[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="admin_email" id="admin_email" style="width:244px;" value="{ADMINEMAIL}" />
                            <br />
                            
                            <span class="label130">
                                [l]Organization[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="org_name" id="org_name" style="width:244px;" value="{ORGANIZATION}" />
                            <br />
                            
                            <span class="label130">
                                [l]First Name[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="first_name" id="first_name" style="width:244px;" value="{FNAME}" />
                            <br />
                            
                            <span class="label130">
                                [l]Last Name[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="last_name" id="last_name" style="width:244px;" value="{LNAME}" />
                            <br />
                            
                            <span class="label130">
                                [l]E-mail[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="email" id="email" style="width:244px;" value="{EMAIL}" />
                            <br />
                            
                            <span class="label130">
                                [l]Address Line[/l] 1 :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="address1" id="address1" style="width:244px;" value="{ADDRESS1}" />
                            <br />
                            
                            <span class="label130">
                                [l]Address Line[/l] 2 :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="address2" id="address2" style="width:244px;" value="{ADDRESS2}" />
                            <br />
                            
                            <span class="label130">
                                [l]Address Line[/l] 3 :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="address3" id="address3" style="width:244px;" value="{ADDRESS3}" />
                            <br />
                            
                            <span class="label130">
                                [l]City[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="city" id="city" style="width:244px;" value="{CITY}" />
                            <br />
                            
                            <span class="label130">
                                [l]State[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="state" id="state" style="width:244px;" style="width:244px;" value="{STATE}" />
                            <br />
                            
                            <span class="label130">
                                [l]Country[/l] :
                            </span>
                            <select name="country" id="country"  style="width:248px;">
                                {COUNTRY}
                            </select>
                            <br />
                            
                            <span class="label130">
                                [l]Postal Code[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="postal_code" id="postal_code" style="width:244px;" value="{POSTALCODE}" />
                            <br />
                            
                            <span class="label130">
                                [l]Phone[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="phone" id="phone" style="width:244px;" value="{PHONE}" />
                            <br />
                            
                            <span class="label130">
                                [l]Fax[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="fax" id="fax" style="width:244px;" value="{FAX}" />
                            <br />
                            
                            <!--
                            <span class="label130">
                                [l]Nameserver[/l] 1 :
                            </span>
                            <input type="text" name="fqdn1" id="fqdn1" style="width:244px;" value="{FQDN1}" />
                            <br />
                            
                            <span class="label130">
                                [l]Nameserver[/l] 2 :
                            </span>
                            <input type="text" name="fqdn2" id="fqdn2" style="width:244px;" value="{FQDN2}" />
                            <br />
                            
                            <span class="label130">
                                [l]Nameserver[/l] 3 :
                            </span>
                            <input type="text" name="fqdn3" id="fqdn3" style="width:244px;" value="{FQDN3}" />
                            <br />
                            -->
                            
                            <span class="label130">
                                [l]Username[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="username" id="username" style="width:244px;" value="{ID}" />
                            <br />
                            
                            <span class="label130">
                                [l]Password[/l] :
                            </span>
                            <input type="text" class="x-form-text x-form-field" name="password" id="password" style="width:244px;" value="{PW}" />
                            <br />
                            <span class="label130">[l]ClientExec Domain[/l] :</span>
                            <input class="x-form-text x-form-field" type="text" name="domain" id="domain" value="" style="width: 244px;" />
                            <br />
                            <div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">
                            </div>
                            <div style='margin-top:10px;float:left;overflow:hidden;'>
                                <input type="checkbox" name="agree" />
                                <a href="plugins/snapins/opensrsform/Services_Agreement.html" target="_blank">Agree to the TUCOWS master services agreement</a> 
                            </div>
                        </div>
                    </fieldset>
                    
                    <div class="st_submit">
                        <input type="submit" name="submit" value='[l]Sign Up[/l]' />
                    </div>
                </form>
                <!-- END DYNAMIC BLOCK: signupForm -->
                
                <!-- BEGIN DYNAMIC BLOCK: successPage -->
                {SUCCESSMESSAGE}
                <!-- END DYNAMIC BLOCK: successPage -->
            </li>
        </ul>
    </div>
</div>