139 lines
5.7 KiB
Plaintext
139 lines
5.7 KiB
Plaintext
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<html>
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<head>
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<meta name="GENERATOR" content="Microsoft FrontPage 3.0">
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<base face="Arial">
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<title>Secure Order Form</title>
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</head>
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<body bgcolor="#FFFFFF" link="#0000FF" vlink="#800000">
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<div align="left">
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<table border="0" cellpadding="0" cellspacing="0">
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<tr>
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<td width="125"><font color="#FF0000"><big>Aawsom<br>
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Technologies</big></font></td>
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<td width="5"></td>
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<td><h1><font color="#FF0000">Secure Order Form</font></h1>
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</td>
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</tr>
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<tr>
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<td width="125"></td>
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<td width="5" bgcolor="#FFFFFF"></td>
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<td bgcolor="#FFFFFF" align="left"><font face="Arial"><table border="5">
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<tr>
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<td>
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<!-- Start Insert Here -->
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<form action="https://Secure2.Aawsom.net/forms/FormProcessor.asp" method="POST" name="Comment_Form">
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<input type="hidden" name="MailTo" value="Support@Aawsom.net">
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<input type="hidden" name="MailFromDefault" value="NoEmail@Aawsom.net">
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<input type="hidden" name="MailFromField" value="Email">
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<input type="hidden" name="MailSubject" value="Test Form">
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<input type="hidden" name="MailRedirect" value="Aawsom.net">
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<%' <input type="hidden" name="MailRedirectSecure" value="Secure2.Aawsom.net/VirtualXXX/YourUsername/secure/thanks.htm">%>
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<input type="hidden" name="Time" value="<%=Now()%>">
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<input type="hidden" name="Browser" value="<%=Request.ServerVariables("HTTP_User_Agent")%>">
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<!-- End Insert Here -->
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<hr width="60%" color="#FF0000">
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<p>Please provide the following ordering information:</p>
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<table>
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<tr>
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<td><strong>QTY</strong></td>
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<td><strong>DESCRIPTION</strong></td>
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</tr>
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<tr>
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<td><input TYPE="TEXT" NAME="Order_Qty0" SIZE="6" MAXLENGTH="6"></td>
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<td><input TYPE="TEXT" NAME="Order_Dsc0" SIZE="45"></td>
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</tr>
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<tr>
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<td><input TYPE="TEXT" NAME="Order_Qty1" SIZE="6" MAXLENGTH="6"></td>
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<td><input TYPE="TEXT" NAME="Order_Dsc1" SIZE="45"></td>
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</tr>
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<tr>
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<td><input TYPE="TEXT" NAME="Order_Qty2" SIZE="6" MAXLENGTH="6"></td>
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<td><input TYPE="TEXT" NAME="Order_Dsc2" SIZE="45"></td>
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</tr>
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<tr>
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<td><input TYPE="TEXT" NAME="Order_Qty3" SIZE="6" MAXLENGTH="6"></td>
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<td><input TYPE="TEXT" NAME="Order_Dsc3" SIZE="45"></td>
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</tr>
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<tr>
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<td><input TYPE="TEXT" NAME="Order_Qty4" SIZE="6" MAXLENGTH="6"></td>
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<td><input TYPE="TEXT" NAME="Order_Dsc4" SIZE="45"></td>
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</tr>
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<tr>
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<td><strong>BILLING</strong></td>
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<td></td>
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</tr>
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<tr>
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<td><em>Credit card</em></td>
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<td><select NAME="Card__Type" size="1">
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<option SELECTED>VISA </option>
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<option>MasterCard </option>
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<option>American Express </option>
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<option>Diner's Club </option>
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<option>Discover </option>
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</select> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Cardholder name</em></td>
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<td><input TYPE="TEXT" NAME="Card_Name" SIZE="35"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Card number</em></td>
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<td><input TYPE="TEXT" NAME="Card_Nmbr" SIZE="35"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Expiration date</em></td>
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<td><input TYPE="TEXT" NAME="Card__Exp" SIZE="5" MAXLENGTH="5"> </td>
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</tr>
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<tr>
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<td><strong>SHIPPING</strong></td>
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<td></td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Street address</em></td>
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<td><input TYPE="TEXT" NAME="Addrs_Str1" SIZE="35"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Address (cont.)</em></td>
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<td><input TYPE="TEXT" NAME="Addrs_Str2" SIZE="35"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>City</em></td>
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<td><input TYPE="TEXT" NAME="Addrs_City" SIZE="35"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>State/Province</em></td>
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<td><input TYPE="TEXT" NAME="Addrs_Stat" SIZE="35"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Zip/Postal code</em></td>
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<td><input TYPE="TEXT" NAME="Addrs__Zip" SIZE="12" MAXLENGTH="12"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Country</em></td>
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<td><input TYPE="TEXT" NAME="Addrs_Ctry" SIZE="25"> </td>
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</tr>
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<tr>
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<td ALIGN="right"><em>Email Address</em></td>
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<td><input TYPE="TEXT" NAME="Email" SIZE="25"> </td>
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</tr>
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</table>
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<div align="center"><center><p><input TYPE="submit" VALUE="Submit Form"> </p>
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</center></div><hr width="60%" color="#FF0000">
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<div align="center"><center><p><font><small>Designed by: <a href="http://www.Aawsom.net/sitedesign">Aawsom Technologies</a></small></font><br>
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<font color="#000000" face="Arial" size="1">Revised: <!--webbot bot="Timestamp" S-Type="EDITED" S-Format="%m/%d/%y %I:%M %p" startspan -->09/10/98 01:52 PM<!--webbot bot="Timestamp" endspan i-checksum="29431" --></font></p>
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</center></div><div align="center"><center><p></font> </p>
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</center></div>
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</form>
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</td>
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</tr>
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</table>
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</td>
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</tr>
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</table>
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</div>
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</body>
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</html>
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