<div style="margin-bottom: 10px; margin-top: 10px;" class="table-summary">
    <h2>ClientExec Enom Registration Form</h2><br/>
    {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-description></font></td>
    <td class="snapshot-header" align=right></td>
    <td class="snapshot-header-right"></td></tr>
</table>
<!-- BEGIN DYNAMIC BLOCK: signupForm -->
<div align="center" style="color:red">{ERR}</div>

<div>
<form method='post' action='index.php?fuse=admin&amp;view=Snapins&amp;plugin=enomform'>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Organization:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="org" size="30" value="{ORGANIZATION}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Title: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="title" size="30" value="{TITLE}"/></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">First Name:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="fname" size="30" value="{FNAME}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Last Name:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="lname" size="30" value="{LNAME}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Email: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="email" size="30" value="{EMAIL}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Address: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="address" size="30" value="{ADDRESS}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">City: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="city" size="30" value="{CITY}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">State: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="state" size="30" value="{STATE}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Country: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="country" size="30" value="{COUNTRY}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Zip Code: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="zip" size="30" value="{ZIPCODE}" /></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Phone: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="phone" size="30" value="{PHONE}" /></div>

<!-- reseller plugin details -->
<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Account Type:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'><select name="accounttype"><option value="1">Reseller Account</option><option value="0" {RETAIL}>Retail Account</option></select></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Preferred Username:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="username" size="30" value="{ID}"/></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Password:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="password" name="password" size="30" value="{PW}"/></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Password Confirmation:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="password" name="password2" size="30" value="{PW2}"/></div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Secret Word Type:</div>
<div style='margin-top:10px;float:left;overflow:hidden;'>
<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>
</div>

<div style="clear:both;margin-top:10px;float:left;width:105px;margin-left:10px;margin-right:10px;">Secret Word: </div>
<div style='margin-top:10px;float:left;overflow:hidden;'><input type="text" name="sword" size="30" value="{ANS}" /></div>
<div style="clear:both;padding-top:15px;">
    <input type="submit" class="button" name="submit" value='Sign Up' />
</div>
</form>

<!-- END DYNAMIC BLOCK: signupForm -->
<!-- BEGIN DYNAMIC BLOCK: successPage -->
<div style="clear:both;padding-top:15px;">
{SUCCESSMESSAGE}
</div>
<!-- END DYNAMIC BLOCK: successPage -->

