<div>
    <div id="kb" class="block">
        <div class="block_title">
            <h3><b><a href="#">[l]Support Center[/l]</a> &raquo; <a href="#">[l]Order CDGcommerce Account[/l]</a></b></h3>
        </div>
        <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=cdgcommerceform&amp;public=1'>
                    <fieldset>
                        <legend>[l]CDGcommerce Account Registration Form[/l]</legend>
                        <div class="razmak">
                            <div style="float: left; width:100%"><font class=snapshot-subheader-text>Business Names</font></div>
                            <span class="label185">[l]Exact Legal Business Name[/l] : <font color="red">*</font></span>
                            <input type="text" name="LegalName" id="LegalName" value="{LEGALNAME}" />
                            &nbsp;&nbsp;{LegalNamePopup}
                            <br />
                            <span class="label185">[l]Legal Physical Address[/l] : <font color="red">*</font></span>
                            <input type="text" name="LegalAddress" id="LegalAddress" value="{LEGALADDRESS}" />
                            &nbsp;&nbsp;{LegalAddressPopup}
                            <br />
                            <span class="label185">[l]Legal Physical City[/l] : <font color="red">*</font></span>
                            <input type="text" name="LegalCity" id="LegalCity" value="{LEGALCITY}" />
                            &nbsp;&nbsp;{LegalCityPopup}
                            <br />
                            <span class="label185">[l]Legal Physical State[/l] : <font color="red">*</font></span>
                            <input type="text" name="LegalState" id="LegalState" value="{LEGALSTATE}" />
                            &nbsp;&nbsp;{LegalStatePopup}
                            <br />
                            <span class="label185">[l]Legal Physical Zip Code[/l] : <font color="red">*</font></span>
                            <input type="text" name="LegalZip" id="LegalZip" value="{LEGALZIP}" />
                            &nbsp;&nbsp;{LegalZipPopup}
                            <br />
                            <span class="label185">[l]Legal Phone Number[/l] : <font color="red">*</font></span>
                            <input type="text" name="LegalPhone" id="LegalPhone" value="{LEGALPHONE}" />
                            &nbsp;&nbsp;{LegalPhonePopup}
                            <br />
                            <span class="label185">[l]Legal Fax Number[/l] : </span>
                            <input type="text" name="LegalFax" id="LegalFax" value="{LEGALFAX}" />
                            &nbsp;&nbsp;{LegalFaxPopup}
                            <br />
                            <span class="label185">[l]Valid Email Address[/l] : <font color="red">*</font></span>
                            <input type="text" name="LegalEmail" id="LegalEmail" value="{LEGALEMAIL}" />
                            &nbsp;&nbsp;{LegalEmailPopup}
                            <br />
                            <span class="label185">[l]Sole Proprietor Use SSN[/l] : <font color="red">*</font></span>
                            <input type="text" name="FedTaxId" id="FedTaxId" value="{FEDTAXID}" />
                            &nbsp;&nbsp;{FedTaxIdPopup}
                            <br />
                            <span class="label185">[l]Doing Business As[/l] : <font color="red">*</font></span>
                            <input type="text" name="DBAName" id="DBAName" value="{DBANAME}" />
                            &nbsp;&nbsp;{DBANamePopup}
                            <br />
                            <span class="label185">[l]Doing Business As Address[/l] : <font color="red">*</font></span>
                            <input type="text" name="DBAAddress" id="DBAAddress" value="{DBAADDRESS}" />
                            &nbsp;&nbsp;{DBAAddressPopup}
                            <br />
                            <span class="label185">[l]Doing Business As City[/l] : <font color="red">*</font></span>
                            <input type="text" name="DBACity" id="DBACity" value="{DBACITY}" />
                            &nbsp;&nbsp;{DBACityPopup}
                            <br />
                            <span class="label185">[l]Doing Business As State[/l] : <font color="red">*</font></span>
                            <input type="text" name="DBAState" id="DBAState" value="{DBASTATE}" />
                            &nbsp;&nbsp;{DBAStatePopup}
                            <br />
                            <span class="label185">[l]Doing Business As Zip Code[/l] : <font color="red">*</font></span>
                            <input type="text" name="DBAZip" id="DBAZip" value="{DBAZIP}" />
                            &nbsp;&nbsp;{DBAZipPopup}
                            <br />
                            <span class="label185">[l]Main Contact Person[/l] : <font color="red">*</font></span>
                            <input type="text" name="DBAContact" id="DBAContact" value="{DBACONTACT}" />
                            &nbsp;&nbsp;{DBAContactPopup}
                            <br />
                            <span class="label185">[l]Doing Business As Phone[/l] : <font color="red">*</font></span>
                            <input type="text" name="DBAPhone" id="DBAPhone" value="{DBAPHONE}" />
                            &nbsp;&nbsp;{DBAPhonePopup}
                            <br />
                            <br />
                            <div style="float: left; width:100%"><font class=snapshot-subheader-text>Merchant Profile</font></div>
                            <span class="label185">[l]Type Of Organization[/l] : <font color="red">*</font></span>
                            <select name="OrganizationType" id="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}
                            <br />
                            <span class="label185">[l]Years In Business[/l] : <font color="red">*</font></span>
                            <input type="text" name="TimeInBusiness" id="TimeInBusiness" value="{TIMEINBUSINESS}" />
                            &nbsp;&nbsp;{TimeInBusinessPopup}
                            <br />
                            <span class="label185">[l]Products Or Services Sold[/l] : <font color="red">*</font></span>
                            <input type="text" name="Products" id="Products" value="{PRODUCTS}" />
                            &nbsp;&nbsp;{ProductsPopup}
                            <br />
                            <span class="label185">[l]Merchant Type[/l] : <font color="red">*</font></span>
                            <select name="MerchantType" id="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}
                            <br />
                            <span class="label185">[l]Other Merchant Type[/l] : </span>
                            <input type="text" name="MerchantTypeOther" id="MerchantTypeOther" value="{MERCHANTTYPEOTHER}" />
                            &nbsp;&nbsp;{MerchantTypeOtherPopup}
                            <br />
                            <span class="label185">[l]Specific Gateway Or Retail Device[/l] : </span>
                            <select name="PosType" id="PosType">
                                <option value="QuantumGateway">Quantum Gateway</option>
                                <option value="Authnet" {AUTHNET}>Authorize.Net</option>
                                <option value="ePN" {EPN}>eProcessingNetwork</option>
                            </select>
                            &nbsp;&nbsp;{PosTypePopup}
                            <br />
                            <span class="label185">[l]Anticipated Monthly Sales[/l] : <font color="red">*</font></span>
                            <input type="text" name="MonthlyVolume" id="MonthlyVolume" value="{MONTHLYVOLUME}" />
                            &nbsp;&nbsp;{MonthlyVolumePopup}
                            <br />
                            <span class="label185">[l]Average Sale Amount[/l] : <font color="red">*</font></span>
                            <input type="text" name="AverageAmount" id="AverageAmount" value="{AVERAGEAMOUNT}" />
                            &nbsp;&nbsp;{AverageAmountPopup}
                            <br />
                            <span class="label185">[l]Highest Sale Amount[/l] : <font color="red">*</font></span>
                            <input type="text" name="HighestAmount" id="HighestAmount" value="{HIGHESTAMOUNT}" />
                            &nbsp;&nbsp;{HighestAmountPopup}
                            <br />
                            <span class="label185">[l]Business seasonally only[/l] : </span>
                            <select name="Seasonal" id="Seasonal">
                                <option value="N">No</option>
                                <option value="Y" {SEASONAL}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{SeasonalPopup}
                            <br />
                            <span class="label185">[l]Third Party Payment Process[/l] : </span>
                            <select name="ThirdPartyPaymentProcess" id="ThirdPartyPaymentProcess">
                                <option value="N">No</option>
                                <option value="Y" {THIRDPARTYPAYMENTPROCESS}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{ThirdPartyPaymentProcessPopup}
                            <br />
                            <span class="label185">[l]Third Party Payment Processors[/l] : </span>
                            <input type="text" name="ThirdPartyPaymentProcessors" id="ThirdPartyPaymentProcessors" value="{THIRDPARTYPAYMENTPROCESSORS}" />
                            &nbsp;&nbsp;{ThirdPartyPaymentProcessorsPopup}
                            <br />
                            <span class="label185">[l]When is the cardholder billed[/l] : </span>
                            <select name="CardHolderBilled" id="CardHolderBilled">
                                <option value="NotApplicable">Not Applicable</option>
                                <option value="OnOrder" {ONORDER}>On Order</option>
                                <option value="Shipment" {SHIPMENT}>Shipment</option>
                            </select>
                            &nbsp;&nbsp;{CardHolderBilledPopup}
                            <br />
                            <span class="label185">[l]Internet Service Provider[/l] : <font color="red">**</font></span>
                            <input type="text" name="ServiceProvider" id="ServiceProvider" value="{SERVICEPROVIDER}" />
                            &nbsp;&nbsp;{ServiceProviderPopup}
                            <br />
                            <span class="label185">[l]Secure Certificate[/l] : <font color="red">**</font></span>
                            <select name="SecureSSL" id="SecureSSL">
                                <option value="N">No</option>
                                <option value="Y" {SECURESSL}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{SecureSSLPopup}
                            <br />
                            <span class="label185">[l]Main Web Page Address[/l] : <font color="red">*</font></span>
                            <input type="text" name="WebURL" id="WebURL" value="{WEBURL}" />
                            &nbsp;&nbsp;{WebURLPopup}
                            <br />
                            <span class="label185">[l]All URLs that will process[/l] : <font color="red">**</font></span>
                            <input type="text" name="AllUrls" id="AllUrls" value="{ALLURLS}" />
                            &nbsp;&nbsp;{AllUrlsPopup}
                            <br />
                            <span class="label185">[l]Do you use a fulfillment center[/l] : <font color="red">**</font></span>
                            <select name="FullfillmentCenter" id="FullfillmentCenter">
                                <option value="N">No</option>
                                <option value="Y" {FULLFILLMENTCENTER}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{FullfillmentCenterPopup}
                            <br />
                            <span class="label185">[l]Info about the fulfillment center[/l] : </span>
                            <input type="text" name="FullFillmentCenterInfo" id="FullFillmentCenterInfo" value="{FULLFILLMENTCENTERINFO}" />
                            &nbsp;&nbsp;{FullFillmentCenterInfoPopup}
                            <br />
                            <span class="label185">[l]Delivery Of Products[/l] : </span>
                            <select name="DeliveryOfProducts" id="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}
                            <br />
                            <span class="label185">[l]Do you have a refund policy[/l] : </span>
                            <select name="RefundPolicy" id="RefundPolicy">
                                <option value="N">No</option>
                                <option value="Y" {REFUNDPOLICY}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{RefundPolicyPopup}
                            <br />
                            <br />
                            <div style="float: left; width:100%"><font class=snapshot-subheader-text>Owners and Officers</font></div>
                            <span class="label185">[l]Principal Owner's Name[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalOwner" id="PrincipalOwner" value="{PRINCIPALOWNER}" />
                            &nbsp;&nbsp;{PrincipalOwnerPopup}
                            <br />
                            <span class="label185">[l]Principal % Ownership[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalPercent" id="PrincipalPercent" value="{PRINCIPALPERCENT}" />
                            &nbsp;&nbsp;{PrincipalPercentPopup}
                            <br />
                            <span class="label185">[l]Principal Owner's SSN1[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalSSN1" id="PrincipalSSN1" value="{PRINCIPALSSN1}" />
                            &nbsp;&nbsp;{PrincipalSSN1Popup}
                            <br />
                            <span class="label185">[l]Principal Owner's SSN2[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalSSN2" id="PrincipalSSN2" value="{PRINCIPALSSN2}" />
                            &nbsp;&nbsp;{PrincipalSSN2Popup}
                            <br />
                            <span class="label185">[l]Principal Owner's SSN3[/l] : <font color="red">*</font></span>
                            <input type="text" name="PrincipalSSN3" id="PrincipalSSN3" value="{PRINCIPALSSN3}" />
                            &nbsp;&nbsp;{PrincipalSSN3Popup}
                            <br />
                            <span class="label185">[l]Principal Owner's Phone[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalPhone" id="PrincipalPhone" value="{PRINCIPALPHONE}" />
                            &nbsp;&nbsp;{PrincipalPhonePopup}
                            <br />
                            <span class="label185">[l]Principal Owner's Address[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalAddress" id="PrincipalAddress" value="{PRINCIPALADDRESS}" />
                            &nbsp;&nbsp;{PrincipalAddressPopup}
                            <br />
                            <span class="label185">[l]Principal Owner's City[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalCity" id="PrincipalCity" value="{PRINCIPALCITY}" />
                            &nbsp;&nbsp;{PrincipalCityPopup}
                            <br />
                            <span class="label185">[l]Principal Owner's State[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalState" id="PrincipalState" value="{PRINCIPALSTATE}" />
                            &nbsp;&nbsp;{PrincipalStatePopup}
                            <br />
                            <span class="label185">[l]Principal Owner's Zip Code[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalZip" id="PrincipalZip" value="{PRINCIPALZIP}" />
                            &nbsp;&nbsp;{PrincipalZipPopup}
                            <br />
                            <span class="label185">[l]Principal Owner's Birth Date[/l] : <font color="red">****</font></span>
                            <input type="text" name="PrincipalDOB" id="PrincipalDOB" value="{PRINCIPALDOB}" />
                            &nbsp;&nbsp;{PrincipalDOBPopup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's Name[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2Owner" id="Principal2Owner" value="{PRINCIPAL2OWNER}" />
                            &nbsp;&nbsp;{Principal2OwnerPopup}
                            <br />
                            <span class="label185">[l]Principal2 % Ownership[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2Percent" id="Principal2Percent" value="{PRINCIPAL2PERCENT}" />
                            &nbsp;&nbsp;{Principal2PercentPopup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's SSN1[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2SSN1" id="Principal2SSN1" value="{PRINCIPAL2SSN1}" />
                            &nbsp;&nbsp;{Principal2SSN1Popup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's SSN2[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2SSN2" id="Principal2SSN2" value="{PRINCIPAL2SSN2}" />
                            &nbsp;&nbsp;{Principal2SSN2Popup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's SSN3[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2SSN3" id="Principal2SSN3" value="{PRINCIPAL2SSN3}" />
                            &nbsp;&nbsp;{Principal2SSN3Popup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's Phone[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2Phone" id="Principal2Phone" value="{PRINCIPAL2PHONE}" />
                            &nbsp;&nbsp;{Principal2PhonePopup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's Address[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2Address" id="Principal2Address" value="{PRINCIPAL2ADDRESS}" />
                            &nbsp;&nbsp;{Principal2AddressPopup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's City[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2City" id="Principal2City" value="{PRINCIPAL2CITY}" />
                            &nbsp;&nbsp;{Principal2CityPopup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's State[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2State" id="Principal2State" value="{PRINCIPAL2STATE}" />
                            &nbsp;&nbsp;{Principal2StatePopup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's Zip Code[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2Zip" id="Principal2Zip" value="{PRINCIPAL2ZIP}" />
                            &nbsp;&nbsp;{Principal2ZipPopup}
                            <br />
                            <span class="label185">[l]Principal2 Owner's Birth Date[/l] : <font color="red">***</font></span>
                            <input type="text" name="Principal2DOB" id="Principal2DOB" value="{PRINCIPAL2DOB}" />
                            &nbsp;&nbsp;{Principal2DOBPopup}
                            <br />
                            <span class="label185">[l]VISA/MC merchant account[/l] : </span>
                            <select name="CurrentlyAcceptVisaMC" id="CurrentlyAcceptVisaMC">
                                <option value="N">No</option>
                                <option value="Y" {CURRENTLYACCEPTVISAMC}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{CurrentlyAcceptVisaMCPopup}
                            <br />
                            <span class="label185">[l]Terminated as a VISA/MC merch.[/l] : </span>
                            <select name="TerminatedVMC" id="TerminatedVMC">
                                <option value="N">No</option>
                                <option value="Y" {TERMINATEDVMC}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{TerminatedVMCPopup}
                            <br />
                            <span class="label185">[l]Bankruptcy[/l] : </span>
                            <select name="PrincipalBankruptcy" id="PrincipalBankruptcy">
                                <option value="N">No</option>
                                <option value="Y" {PRINCIPALBANKRUPTCY}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{PrincipalBankruptcyPopup}
                            <br />
                            <span class="label185">[l]Trade References Business Name[/l] : </span>
                            <input type="text" name="TRBusinessName" id="TRBusinessName" value="{TRBUSINESSNAME}" />
                            &nbsp;&nbsp;{TRBusinessNamePopup}
                            <br />
                            <span class="label185">[l]Trade References Contact Name[/l] : </span>
                            <input type="text" name="TRContactName" id="TRContactName" value="{TRCONTACTNAME}" />
                            &nbsp;&nbsp;{TRContactNamePopup}
                            <br />
                            <span class="label185">[l]Trade References Contact Phone[/l] : </span>
                            <input type="text" name="TRContactPhone" id="TRContactPhone" value="{TRCONTACTPHONE}" />
                            &nbsp;&nbsp;{TRContactPhonePopup}
                            <br />
                            <span class="label185">[l]Trade Ref. Business Name 2[/l] : </span>
                            <input type="text" name="TRBusinessName2" id="TRBusinessName2" value="{TRBUSINESSNAME2}" />
                            &nbsp;&nbsp;{TRBusinessName2Popup}
                            <br />
                            <span class="label185">[l]Trade Ref. Contact Name 2[/l] : </span>
                            <input type="text" name="TRContactName2" id="TRContactName2" value="{TRCONTACTNAME2}" />
                            &nbsp;&nbsp;{TRContactName2Popup}
                            <br />
                            <span class="label185">[l]Trade Ref. Contact Phone 2[/l] : </span>
                            <input type="text" name="TRContactPhone2" id="TRContactPhone2" value="{TRCONTACTPHONE2}" />
                            &nbsp;&nbsp;{TRContactPhone2Popup}
                            <br />
                            <span class="label185">[l]Do You Wish To Use Amex[/l] : </span>
                            <select name="ApplyAmex" id="ApplyAmex">
                                <option value="N">No</option>
                                <option value="Y" {APPLYAMEX}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{ApplyAmexPopup}
                            <br />
                            <span class="label185">[l]Do You Wish To Use Discover[/l] : </span>
                            <select name="ApplyDisc" id="ApplyDisc">
                                <option value="N">No</option>
                                <option value="Y" {APPLYDISC}>Yes</option>
                            </select>
                            &nbsp;&nbsp;{ApplyDiscPopup}
                            <br />
                            <span class="label185">[l]Current Amex Number[/l] : </span>
                            <input type="text" name="CurrentAmex" id="CurrentAmex" value="{CURRENTAMEX}" />
                            &nbsp;&nbsp;{CurrentAmexPopup}
                            <br />
                            <span class="label185">[l]Current Discover Number[/l] : </span>
                            <input type="text" name="CurrentDisc" id="CurrentDisc" value="{CURRENTDISC}" />
                            &nbsp;&nbsp;{CurrentDiscPopup}
                            <br />
                            <span class="label185">[l]Name Of Your Bank[/l] : </span>
                            <input type="text" name="BankName" id="BankName" value="{BANKNAME}" />
                            &nbsp;&nbsp;{BankNamePopup}
                            <br />
                            <span class="label185">[l]Branch Contact Number[/l] : </span>
                            <input type="text" name="BranchContactNumber" id="BranchContactNumber" value="{BRANCHCONTACTNUMBER}" />
                            &nbsp;&nbsp;{BranchContactNumberPopup}
                            <br />
                            <span class="label185">[l]Branch Contact[/l] : </span>
                            <input type="text" name="BranchContact" id="BranchContact" value="{BRANCHCONTACT}" />
                            &nbsp;&nbsp;{BranchContactPopup}
                            <br />
                            <span class="label185">[l]Bank Routing Number[/l] : </span>
                            <input type="text" name="BankRoutingNumber" id="BankRoutingNumber" value="{BANKROUTINGNUMBER}" />
                            &nbsp;&nbsp;{BankRoutingNumberPopup}
                            <br />
                            <span class="label185">[l]Bank Account Number[/l] : </span>
                            <input type="text" name="BankAccountNumber" id="BankAccountNumber" value="{BANKACCOUNTNUMBER}" />
                            &nbsp;&nbsp;{BankAccountNumberPopup}
                            <br />
<!--
                            <br />
                            <span class="label185">[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>
            <!-- END DYNAMIC BLOCK: signupForm -->
            <!-- BEGIN DYNAMIC BLOCK: successPage -->
            {SUCCESSMESSAGE}
            <!-- END DYNAMIC BLOCK: successPage -->
            </li>
        </ul>
    </div>
</div>
