148 lines
5.6 KiB
HTML
148 lines
5.6 KiB
HTML
<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 METHOD="POST" action="../_vti_bin/shtml.dll/secure/secureorder.htm" webbot-action="--WEBBOT-SELF--">
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<!--webbot bot="SaveResults"
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U-File="data/secureorder.txt"
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S-Format="TEXT/TSV"
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S-Label-Fields="TRUE"
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B-Reverse-Chronology="FALSE"
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S-Email-Format="TEXT/PRE"
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S-Email-Address="Steve@Aawsom.net"
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B-Email-Label-Fields="TRUE"
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B-Email-ReplyTo-From-Field="True"
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S-Email-ReplyTo="Email"
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B-Email-Subject-From-Field="FALSE"
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S-Email-Subject="Your Secure Order"
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S-Builtin-Fields="Date Time HTTP_USER_AGENT" startspan -->
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<input TYPE="hidden" NAME="VTI-GROUP" VALUE="0">
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<!--webbot bot="SaveResults" endspan i-checksum="43374" -->
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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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