<div align='center'><b>ClientExec CDGcommerce Registration Form</b></div>
<br style="clear: both;">
<div class="yellowbox">
    {SNAPIN_HEADER}
</div>
<br>


<!--
<div align="center" style="color:red">{TEST}</div>
-->

<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>
    CDGcommerce 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>
<!-- BEGIN DYNAMIC BLOCK: signupForm -->
<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=cdgcommerceform'>

<div style="float: left; width:100%"><font class=snapshot-subheader-text>Business Names</font></div>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Exact Legal Business Name: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalName" size="30" value="{LEGALNAME}" />
&nbsp;&nbsp;{LegalNamePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Doing Business As: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="DBAName" size="30" value="{DBANAME}" />
&nbsp;&nbsp;{DBANamePopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Legal Physical Address: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalAddress" size="30" value="{LEGALADDRESS}" />
&nbsp;&nbsp;{LegalAddressPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Doing Business As Address: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="DBAAddress" size="30" value="{DBAADDRESS}" />
&nbsp;&nbsp;{DBAAddressPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Legal Physical City: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalCity" size="30" value="{LEGALCITY}" />
&nbsp;&nbsp;{LegalCityPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Doing Business As City: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="DBACity" size="30" value="{DBACITY}" />
&nbsp;&nbsp;{DBACityPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Legal Physical State: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalState" size="30" value="{LEGALSTATE}" />
&nbsp;&nbsp;{LegalStatePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Doing Business As State: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="DBAState" size="30" value="{DBASTATE}" />
&nbsp;&nbsp;{DBAStatePopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Legal Physical Zip Code: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalZip" size="30" value="{LEGALZIP}" />
&nbsp;&nbsp;{LegalZipPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Doing Business As Zip Code: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="DBAZip" size="30" value="{DBAZIP}" />
&nbsp;&nbsp;{DBAZipPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Legal Phone Number: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalPhone" size="30" value="{LEGALPHONE}" />
&nbsp;&nbsp;{LegalPhonePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Doing Business As Phone: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="DBAPhone" size="30" value="{DBAPHONE}" />
&nbsp;&nbsp;{DBAPhonePopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Legal Fax Number: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalFax" size="30" value="{LEGALFAX}" />
&nbsp;&nbsp;{LegalFaxPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Main Contact Person: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="DBAContact" size="30" value="{DBACONTACT}" />
&nbsp;&nbsp;{DBAContactPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Valid Email Address: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="LegalEmail" size="30" value="{LEGALEMAIL}" />
&nbsp;&nbsp;{LegalEmailPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Sole Proprietor Use SSN: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="FedTaxId" size="30" value="{FEDTAXID}" />
&nbsp;&nbsp;{FedTaxIdPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<br>

<div style="float: left; width:100%"><font class=snapshot-subheader-text>Merchant Profile</font></div>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Type Of Organization: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<select name="OrganizationType">
  <option value="Sole Proprieter">Sole Proprieter</option>
  <option value="Partnership" {PARTNERSHIP}>Partnership</option>
  <option value="Corporation" {CORPORATION}>Corporation</option>
  <option value="LLC" {LLC}>LLC</option>
  <option value="Non-Profit" {NONPROFIT}>Non-Profit</option>
  <option value="Publicly Traded" {PUBLICLYTRADED}>Publicly Traded</option>
</select>
&nbsp;&nbsp;{OrganizationTypePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Third Party Payment Process: </span></span>
<span style="float: left;width:28%;">
<select name="ThirdPartyPaymentProcess">
  <option value="N">No</option>
  <option value="Y" {THIRDPARTYPAYMENTPROCESS}>Yes</option>
</select>
&nbsp;&nbsp;{ThirdPartyPaymentProcessPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Years In Business: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="TimeInBusiness" size="30" value="{TIMEINBUSINESS}" />
&nbsp;&nbsp;{TimeInBusinessPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Third Party Payment Processors: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="ThirdPartyPaymentProcessors" size="30" value="{THIRDPARTYPAYMENTPROCESSORS}" />
&nbsp;&nbsp;{ThirdPartyPaymentProcessorsPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Products Or Services Sold: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Products" size="30" value="{PRODUCTS}" />
&nbsp;&nbsp;{ProductsPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>When is the cardholder billed: </span></span>
<span style="float: left;width:28%;">
<select name="CardHolderBilled">
  <option value="NotApplicable">Not Applicable</option>
  <option value="OnOrder" {ONORDER}>On Order</option>
  <option value="Shipment" {SHIPMENT}>Shipment</option>
</select>
&nbsp;&nbsp;{CardHolderBilledPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Merchant Type: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<select name="MerchantType">
  <option value="retail">Retail</option>
  <option value="restaurant" {RESTAURANT}>Restaurant</option>
  <option value="lodging" {LODGING}>Lodging</option>
  <option value="internet_gateway" {INTERNETGATEWAY}>Internet Gateway</option>
  <option value="moto" {MOTO}>Moto</option>
  <option value="wireless" {WIRELESS}>Wireless</option>
  <option value="other" {OTHER}>Other</option>
</select>
&nbsp;&nbsp;{MerchantTypePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Internet Service Provider: <font color="red">**</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="ServiceProvider" size="30" value="{SERVICEPROVIDER}" />
&nbsp;&nbsp;{ServiceProviderPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Other Merchant Type: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="MerchantTypeOther" size="30" value="{MERCHANTTYPEOTHER}" />
&nbsp;&nbsp;{MerchantTypeOtherPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Secure Certificate: <font color="red">**</font></span></span>
<span style="float: left;width:28%;">
<select name="SecureSSL">
  <option value="N">No</option>
  <option value="Y" {SECURESSL}>Yes</option>
</select>
&nbsp;&nbsp;{SecureSSLPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Specific Gateway Or Retail Device: </span></span>
<span style="float: left;width:28%;">
<select name="PosType">
  <option value="QuantumGateway">Quantum Gateway</option>
  <option value="Authnet" {AUTHNET}>Authorize.Net</option>
  <option value="ePN" {EPN}>eProcessingNetwork</option>
</select>
&nbsp;&nbsp;{PosTypePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Main Web Page Address: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="WebURL" size="30" value="{WEBURL}" />
&nbsp;&nbsp;{WebURLPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Anticipated Monthly Sales: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="MonthlyVolume" size="30" value="{MONTHLYVOLUME}" />
&nbsp;&nbsp;{MonthlyVolumePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>All URLs that will process: <font color="red">**</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="AllUrls" size="30" value="{ALLURLS}" />
&nbsp;&nbsp;{AllUrlsPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Average Sale Amount: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="AverageAmount" size="30" value="{AVERAGEAMOUNT}" />
&nbsp;&nbsp;{AverageAmountPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Do you use a fulfillment center: <font color="red">**</font></span></span>
<span style="float: left;width:28%;">
<select name="FullfillmentCenter">
  <option value="N">No</option>
  <option value="Y" {FULLFILLMENTCENTER}>Yes</option>
</select>
&nbsp;&nbsp;{FullfillmentCenterPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Highest Sale Amount: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="HighestAmount" size="30" value="{HIGHESTAMOUNT}" />
&nbsp;&nbsp;{HighestAmountPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Info about the fulfillment center: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="FullFillmentCenterInfo" size="30" value="{FULLFILLMENTCENTERINFO}" />
&nbsp;&nbsp;{FullFillmentCenterInfoPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Business seasonally only: </span></span>
<span style="float: left;width:28%;">
<select name="Seasonal">
  <option value="N">No</option>
  <option value="Y" {SEASONAL}>Yes</option>
</select>
&nbsp;&nbsp;{SeasonalPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Do you have a refund policy: </span></span>
<span style="float: left;width:28%;">
<select name="RefundPolicy">
  <option value="N">No</option>
  <option value="Y" {REFUNDPOLICY}>Yes</option>
</select>
&nbsp;&nbsp;{RefundPolicyPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Delivery Of Products: </span></span>
<span style="float: left;width:28%;">
<select name="DeliveryOfProducts">
  <option value="1-3 Days">1-3 Days</option>
  <option value="3-5 Days" {3TO5DAYS}>3-5 Days</option>
  <option value="5-15 Days" {5TO15DAYS}>5-15 Days</option>
  <option value="15 Days+" {15DAYSPLUS}>15 Days+</option>
</select>
&nbsp;&nbsp;{DeliveryOfProductsPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<br>

<div style="float: left; width:100%"><font class=snapshot-subheader-text>Owners and Officers</font></div>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's Name: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalOwner" size="30" value="{PRINCIPALOWNER}" />
&nbsp;&nbsp;{PrincipalOwnerPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's Name: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2Owner" size="30" value="{PRINCIPAL2OWNER}" />
&nbsp;&nbsp;{Principal2OwnerPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal % Ownership: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalPercent" size="30" value="{PRINCIPALPERCENT}" />
&nbsp;&nbsp;{PrincipalPercentPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 % Ownership: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2Percent" size="30" value="{PRINCIPAL2PERCENT}" />
&nbsp;&nbsp;{Principal2PercentPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's SSN1: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalSSN1" size="30" value="{PRINCIPALSSN1}" />
&nbsp;&nbsp;{PrincipalSSN1Popup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's SSN1: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2SSN1" size="30" value="{PRINCIPAL2SSN1}" />
&nbsp;&nbsp;{Principal2SSN1Popup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's SSN2: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalSSN2" size="30" value="{PRINCIPALSSN2}" />
&nbsp;&nbsp;{PrincipalSSN2Popup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's SSN2: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2SSN2" size="30" value="{PRINCIPAL2SSN2}" />
&nbsp;&nbsp;{Principal2SSN2Popup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's SSN3: <font color="red">*</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalSSN3" size="30" value="{PRINCIPALSSN3}" />
&nbsp;&nbsp;{PrincipalSSN3Popup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's SSN3: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2SSN3" size="30" value="{PRINCIPAL2SSN3}" />
&nbsp;&nbsp;{Principal2SSN3Popup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's Phone: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalPhone" size="30" value="{PRINCIPALPHONE}" />
&nbsp;&nbsp;{PrincipalPhonePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's Phone: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2Phone" size="30" value="{PRINCIPAL2PHONE}" />
&nbsp;&nbsp;{Principal2PhonePopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's Address: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalAddress" size="30" value="{PRINCIPALADDRESS}" />
&nbsp;&nbsp;{PrincipalAddressPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's Address: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2Address" size="30" value="{PRINCIPAL2ADDRESS}" />
&nbsp;&nbsp;{Principal2AddressPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's City: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalCity" size="30" value="{PRINCIPALCITY}" />
&nbsp;&nbsp;{PrincipalCityPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's City: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2City" size="30" value="{PRINCIPAL2CITY}" />
&nbsp;&nbsp;{Principal2CityPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's State: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalState" size="30" value="{PRINCIPALSTATE}" />
&nbsp;&nbsp;{PrincipalStatePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's State: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2State" size="30" value="{PRINCIPAL2STATE}" />
&nbsp;&nbsp;{Principal2StatePopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's Zip Code: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalZip" size="30" value="{PRINCIPALZIP}" />
&nbsp;&nbsp;{PrincipalZipPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's Zip Code: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2Zip" size="30" value="{PRINCIPAL2ZIP}" />
&nbsp;&nbsp;{Principal2ZipPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal Owner's Birth Date: <font color="red">****</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="PrincipalDOB" size="30" value="{PRINCIPALDOB}" />
&nbsp;&nbsp;{PrincipalDOBPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Principal2 Owner's Birth Date: <font color="red">***</font></span></span>
<span style="float: left;width:28%;">
<input type="text" name="Principal2DOB" size="30" value="{PRINCIPAL2DOB}" />
&nbsp;&nbsp;{Principal2DOBPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>VISA/MC merchant account: </span></span>
<span style="float: left;width:28%;">
<select name="CurrentlyAcceptVisaMC">
  <option value="N">No</option>
  <option value="Y" {CURRENTLYACCEPTVISAMC}>Yes</option>
</select>
&nbsp;&nbsp;{CurrentlyAcceptVisaMCPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Terminated as a VISA/MC merch.: </span></span>
<span style="float: left;width:28%;">
<select name="TerminatedVMC">
  <option value="N">No</option>
  <option value="Y" {TERMINATEDVMC}>Yes</option>
</select>
&nbsp;&nbsp;{TerminatedVMCPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Bankruptcy: </span></span>
<span style="float: left;width:28%;">
<select name="PrincipalBankruptcy">
  <option value="N">No</option>
  <option value="Y" {PRINCIPALBANKRUPTCY}>Yes</option>
</select>
&nbsp;&nbsp;{PrincipalBankruptcyPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Trade References Business Name: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="TRBusinessName" size="30" value="{TRBUSINESSNAME}" />
&nbsp;&nbsp;{TRBusinessNamePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Trade Ref. Business Name 2: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="TRBusinessName2" size="30" value="{TRBUSINESSNAME2}" />
&nbsp;&nbsp;{TRBusinessName2Popup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Trade References Contact Name: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="TRContactName" size="30" value="{TRCONTACTNAME}" />
&nbsp;&nbsp;{TRContactNamePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Trade Ref. Contact Name 2: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="TRContactName2" size="30" value="{TRCONTACTNAME2}" />
&nbsp;&nbsp;{TRContactName2Popup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Trade References Contact Phone: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="TRContactPhone" size="30" value="{TRCONTACTPHONE}" />
&nbsp;&nbsp;{TRContactPhonePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Trade Ref. Contact Phone 2: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="TRContactPhone2" size="30" value="{TRCONTACTPHONE2}" />
&nbsp;&nbsp;{TRContactPhone2Popup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Do You Wish To Use Amex: </span></span>
<span style="float: left;width:28%;">
<select name="ApplyAmex">
  <option value="N">No</option>
  <option value="Y" {APPLYAMEX}>Yes</option>
</select>
&nbsp;&nbsp;{ApplyAmexPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Do You Wish To Use Discover: </span></span>
<span style="float: left;width:28%;">
<select name="ApplyDisc">
  <option value="N">No</option>
  <option value="Y" {APPLYDISC}>Yes</option>
</select>
&nbsp;&nbsp;{ApplyDiscPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Current Amex Number: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="CurrentAmex" size="30" value="{CURRENTAMEX}" />
&nbsp;&nbsp;{CurrentAmexPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Current Discover Number: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="CurrentDisc" size="30" value="{CURRENTDISC}" />
&nbsp;&nbsp;{CurrentDiscPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Name Of Your Bank: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="BankName" size="30" value="{BANKNAME}" />
&nbsp;&nbsp;{BankNamePopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Branch Contact: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="BranchContact" size="30" value="{BRANCHCONTACT}" />
&nbsp;&nbsp;{BranchContactPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Bank Account Number: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="BankAccountNumber" size="30" value="{BANKACCOUNTNUMBER}" />
&nbsp;&nbsp;{BankAccountNumberPopup}
</span>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Branch Contact Number: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="BranchContactNumber" size="30" value="{BRANCHCONTACTNUMBER}" />
&nbsp;&nbsp;{BranchContactNumberPopup}
</span>

<div style='margin-left: 10px;width:95%;' class="viewFormInnerSep"><!-- --></div>

<span style="float: left; width:22%">&nbsp;&nbsp;&nbsp;&nbsp;<span class='rowlabel'>Bank Routing Number: </span></span>
<span style="float: left;width:28%;">
<input type="text" name="BankRoutingNumber" size="30" value="{BANKROUTINGNUMBER}" />
&nbsp;&nbsp;{BankRoutingNumberPopup}
</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>
<!-- END DYNAMIC BLOCK: signupForm -->
<!-- BEGIN DYNAMIC BLOCK: successPage -->
{SUCCESSMESSAGE}
<!-- END DYNAMIC BLOCK: successPage -->