BryanB
02-12-10, 05:49 AM
Can anyone help me with a way to activate the affiliate account automatically when an account is created? I've created a new registration form for affiliates only and would like to add something to it that will set the affiliate account as active once the register... I've basically duplicated the registration page, added some extra fields for affiliates only but now don't know what to add to activate the affiliate account.
<p>Please fill in the fields below to apply for our partner program. Fields marked with a * are required.<br />
<br />
Already have a client account? Click <a href="https://virtualstagingsolutions.com/dashboard/clientarea.php">here</a> to <a href="https://virtualstagingsolutions.com/dashboard/clientarea.php">log in</a>. Then choose the <a href="https://virtualstagingsolutions.com/dashboard/affiliates.php">affiliate link</a> at the top to activate your affiliate account. </p>
<form method="post" action="/dashboard/register.php">
<input type="hidden" name="register" value="true" />
<table width="100%" cellspacing="0" cellpadding="0" class="frame">
<tr>
<td><table width="100%" border="0" cellpadding="10" cellspacing="0">
<tr>
<td width="150" class="fieldarea">First Name</td>
<td><input type="text" name="firstname" size="30" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Last Name</td>
<td><input type="text" name="lastname" size="30" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Company Name</td>
<td><input type="text" name="companyname" size="30" value="" /></td>
</tr>
<tr>
<td class="fieldarea">Email Address</td>
<td><input type="text" name="email" size="50" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Address 1</td>
<td><input type="text" name="address1" size="40" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Address 2</td>
<td><input type="text" name="address2" size="30" value="" /></td>
</tr>
<tr>
<td class="fieldarea">City</td>
<td><input type="text" name="city" size="30" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">State/Region</td>
<td><input type="text" name="state" size="25" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Zip Code</td>
<td><input type="text" name="postcode" size="10" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Country</td>
<td><select name="country"><option value="AF">Afghanistan</option><option value="AX">Aland Islands</option><option value="AL">Albania</option><option value="DZ">Algeria</option><option value="AS">American Samoa</option><option value="AD">Andorra</option><option value="AO">Angola</option><option value="AI">Anguilla</option><option value="AQ">Antarctica</option><option value="AG">Antigua And Barbuda</option><option value="AR">Argentina</option><option value="AM">Armenia</option><option value="AW">Aruba</option><option value="AU">Australia</option><option value="AT">Austria</option><option value="AZ">Azerbaijan</option><option value="BS">Bahamas</option><option value="BH">Bahrain</option><option value="BD">Bangladesh</option><option value="BB">Barbados</option><option value="BY">Belarus</option><option value="BE">Belgium</option><option value="BZ">Belize</option><option value="BJ">Benin</option><option value="BM">Bermuda</option><option value="BT">Bhutan</option><option value="BO">Bolivia</option><option value="BA">Bosnia And Herzegovina</option><option value="BW">Botswana</option><option value="BV">Bouvet Island</option><option value="BR">Brazil</option><option value="IO">British Indian Ocean Territory</option><option value="BN">Brunei Darussalam</option><option value="BG">Bulgaria</option><option value="BF">Burkina Faso</option><option value="BI">Burundi</option><option value="KH">Cambodia</option><option value="CM">Cameroon</option><option value="CA">Canada</option><option value="CV">Cape Verde</option><option value="KY">Cayman Islands</option><option value="CF">Central African Republic</option><option value="TD">Chad</option><option value="CL">Chile</option><option value="CN">China</option><option value="CX">Christmas Island</option><option value="CC">Cocos (Keeling) Islands</option><option value="CO">Colombia</option><option value="KM">Comoros</option><option value="CG">Congo</option><option value="CD">Congo, Democratic Republic</option><option value="CK">Cook Islands</option><option value="CR">Costa Rica</option><option value="CI">Cote D'Ivoire</option><option value="HR">Croatia</option><option value="CU">Cuba</option><option value="CY">Cyprus</option><option value="CZ">Czech Republic</option><option value="DK">Denmark</option><option value="DJ">Djibouti</option><option value="DM">Dominica</option><option value="DO">Dominican Republic</option><option value="EC">Ecuador</option><option value="EG">Egypt</option><option value="SV">El Salvador</option><option value="GQ">Equatorial Guinea</option><option value="ER">Eritrea</option><option value="EE">Estonia</option><option value="ET">Ethiopia</option><option value="FK">Falkland Islands (Malvinas)</option><option value="FO">Faroe Islands</option><option value="FJ">Fiji</option><option value="FI">Finland</option><option value="FR">France</option><option value="GF">French Guiana</option><option value="PF">French Polynesia</option><option value="TF">French Southern Territories</option><option value="GA">Gabon</option><option value="GM">Gambia</option><option value="GE">Georgia</option><option value="DE">Germany</option><option value="GH">Ghana</option><option value="GI">Gibraltar</option><option value="GR">Greece</option><option value="GL">Greenland</option><option value="GD">Grenada</option><option value="GP">Guadeloupe</option><option value="GU">Guam</option><option value="GT">Guatemala</option><option value="GG">Guernsey</option><option value="GN">Guinea</option><option value="GW">Guinea-Bissau</option><option value="GY">Guyana</option><option value="HT">Haiti</option><option value="HM">Heard Island & Mcdonald Islands</option><option value="VA">Holy See (Vatican City State)</option><option value="HN">Honduras</option><option value="HK">Hong Kong</option><option value="HU">Hungary</option><option value="IS">Iceland</option><option value="IN">India</option><option value="ID">Indonesia</option><option value="IR">Iran, Islamic Republic Of</option><option value="IQ">Iraq</option><option value="IE">Ireland</option><option value="IM">Isle Of Man</option><option value="IL">Israel</option><option value="IT">Italy</option><option value="JM">Jamaica</option><option value="JP">Japan</option><option value="JE">Jersey</option><option value="JO">Jordan</option><option value="KZ">Kazakhstan</option><option value="KE">Kenya</option><option value="KI">Kiribati</option><option value="KR">Korea</option><option value="KW">Kuwait</option><option value="KG">Kyrgyzstan</option><option value="LA">Lao People's Democratic Republic</option><option value="LV">Latvia</option><option value="LB">Lebanon</option><option value="LS">Lesotho</option><option value="LR">Liberia</option><option value="LY">Libyan Arab Jamahiriya</option><option value="LI">Liechtenstein</option><option value="LT">Lithuania</option><option value="LU">Luxembourg</option><option value="MO">Macao</option><option value="MK">Macedonia</option><option value="MG">Madagascar</option><option value="MW">Malawi</option><option value="MY">Malaysia</option><option value="MV">Maldives</option><option value="ML">Mali</option><option value="MT">Malta</option><option value="MH">Marshall Islands</option><option value="MQ">Martinique</option><option value="MR">Mauritania</option><option value="MU">Mauritius</option><option value="YT">Mayotte</option><option value="MX">Mexico</option><option value="FM">Micronesia, Federated States Of</option><option value="MD">Moldova</option><option value="MC">Monaco</option><option value="MN">Mongolia</option><option value="ME">Montenegro</option><option value="MS">Montserrat</option><option value="MA">Morocco</option><option value="MZ">Mozambique</option><option value="MM">Myanmar</option><option value="NA">Namibia</option><option value="NR">Nauru</option><option value="NP">Nepal</option><option value="NL">Netherlands</option><option value="AN">Netherlands Antilles</option><option value="NC">New Caledonia</option><option value="NZ">New Zealand</option><option value="NI">Nicaragua</option><option value="NE">Niger</option><option value="NG">Nigeria</option><option value="NU">Niue</option><option value="NF">Norfolk Island</option><option value="MP">Northern Mariana Islands</option><option value="NO">Norway</option><option value="OM">Oman</option><option value="PK">Pakistan</option><option value="PW">Palau</option><option value="PS">Palestinian Territory, Occupied</option><option value="PA">Panama</option><option value="PG">Papua New Guinea</option><option value="PY">Paraguay</option><option value="PE">Peru</option><option value="PH">Philippines</option><option value="PN">Pitcairn</option><option value="PL">Poland</option><option value="PT">Portugal</option><option value="PR">Puerto Rico</option><option value="QA">Qatar</option><option value="RE">Reunion</option><option value="RO">Romania</option><option value="RU">Russian Federation</option><option value="RW">Rwanda</option><option value="BL">Saint Barthelemy</option><option value="SH">Saint Helena</option><option value="KN">Saint Kitts And Nevis</option><option value="LC">Saint Lucia</option><option value="MF">Saint Martin</option><option value="PM">Saint Pierre And Miquelon</option><option value="VC">Saint Vincent And Grenadines</option><option value="WS">Samoa</option><option value="SM">San Marino</option><option value="ST">Sao Tome And Principe</option><option value="SA">Saudi Arabia</option><option value="SN">Senegal</option><option value="RS">Serbia</option><option value="SC">Seychelles</option><option value="SL">Sierra Leone</option><option value="SG">Singapore</option><option value="SK">Slovakia</option><option value="SI">Slovenia</option><option value="SB">Solomon Islands</option><option value="SO">Somalia</option><option value="ZA">South Africa</option><option value="GS">South Georgia And Sandwich Isl.</option><option value="ES">Spain</option><option value="LK">Sri Lanka</option><option value="SD">Sudan</option><option value="SR">Suriname</option><option value="SJ">Svalbard And Jan Mayen</option><option value="SZ">Swaziland</option><option value="SE">Sweden</option><option value="CH">Switzerland</option><option value="SY">Syrian Arab Republic</option><option value="TW">Taiwan</option><option value="TJ">Tajikistan</option><option value="TZ">Tanzania</option><option value="TH">Thailand</option><option value="TL">Timor-Leste</option><option value="TG">Togo</option><option value="TK">Tokelau</option><option value="TO">Tonga</option><option value="TT">Trinidad And Tobago</option><option value="TN">Tunisia</option><option value="TR">Turkey</option><option value="TM">Turkmenistan</option><option value="TC">Turks And Caicos Islands</option><option value="TV">Tuvalu</option><option value="UG">Uganda</option><option value="UA">Ukraine</option><option value="AE">United Arab Emirates</option><option value="GB">United Kingdom</option><option value="US" selected="selected">United States</option><option value="UM">United States Outlying Islands</option><option value="UY">Uruguay</option><option value="UZ">Uzbekistan</option><option value="VU">Vanuatu</option><option value="VE">Venezuela</option><option value="VN">Viet Nam</option><option value="VG">Virgin Islands, British</option><option value="VI">Virgin Islands, U.S.</option><option value="WF">Wallis And Futuna</option><option value="EH">Western Sahara</option><option value="YE">Yemen</option><option value="ZM">Zambia</option><option value="ZW">Zimbabwe</option></select>
*</td>
</tr>
<tr>
<td class="fieldarea">Phone Number</td>
<td><input type="text" name="phonenumber" size="20" value="" />
*</td>
</tr>
</table></td>
</tr>
</table>
<br />
<table width="100%" cellspacing="0" cellpadding="0" class="frame">
<tr>
<td><table width="100%" border="0" cellpadding="10" cellspacing="0">
<tr>
<td class="fieldarea">Please choose a security question</td>
<td><select name="securityqid">
<option value="12">Where were you born?</option>
<option value="5">What was your childhood nickname? </option>
<option value="6">In what city or town was your first job?</option>
<option value="7">What are the last 5 digits of your driver's license number?</option>
<option value="8">What is your first dog's name?</option>
<option value="9">What is your mother's maiden name?</option>
<option value="10">Who is your favorite musician?</option>
<option value="11">What are the last 4 digits of your credit card number?</option>
</select>
*</td>
</tr>
<tr>
<td class="fieldarea">Please enter an answer</td>
<td><input type="password" name="securityqans" size="30" /> *</td>
</tr>
<tr>
<td class="fieldarea">Your Website</td>
<td><input type="text" size="30" name="customfield[1]" value=""> </td>
</tr>
<tr>
<td class="fieldarea">How did you hear about us?</td>
<td><select name="customfield[7]"><option value="-">-</option><option value="Google">Google</option><option value=" Realtor Magazine"> Realtor Magazine</option><option value=" Friend/Colleague"> Friend/Colleague</option><option value=" Newspaper"> Newspaper</option><option value=" Magazine"> Magazine</option><option value=" Email"> Email</option><option value=" Affiliate"> Affiliate</option><option value=" Radio"> Radio</option><option value=" TV"> TV</option><option value=" Trade Show"> Trade Show</option><option value=" Other"> Other</option></select>
* </td>
</tr>
<tr>
<td class="fieldarea">Mobile Phone Number</td>
<td><input type="text" size="30" name="customfield[13]" value=""> </td>
</tr>
<tr>
<td class="fieldarea">What is your primary marketing plan?</td>
<td><select name="customfield[14]"><option value="" selected></option><option value="Pay Per Click">Pay Per Click</option><option value=" My own website"> My own website</option><option value=" Search Engine Optimization"> Search Engine Optimization</option><option value=" Locally"> Locally</option><option value=" TV"> TV</option><option value=" Radio"> Radio</option><option value=" Print"> Print</option><option value=" E-Mail"> E-Mail</option><option value=" Other"> Other</option></select>
* </td>
</tr>
<tr>
<td valign="top" class="fieldarea"><p>Describe your marketing plan</p></td>
<td><textarea name="customfield[15]" cols="60" rows="6"></textarea>
* </td>
</tr>
<tr>
<td class="fieldarea">Social Security Number</td>
<td><input type="text" size="30" name="customfield[16]" value=""> <br />
You may leave this blank but you will need to provide it before we can send your first payment</td>
</tr>
<tr>
</table></td>
</tr>
</table>
</form>
<p>Please fill in the fields below to apply for our partner program. Fields marked with a * are required.<br />
<br />
Already have a client account? Click <a href="https://virtualstagingsolutions.com/dashboard/clientarea.php">here</a> to <a href="https://virtualstagingsolutions.com/dashboard/clientarea.php">log in</a>. Then choose the <a href="https://virtualstagingsolutions.com/dashboard/affiliates.php">affiliate link</a> at the top to activate your affiliate account. </p>
<form method="post" action="/dashboard/register.php">
<input type="hidden" name="register" value="true" />
<table width="100%" cellspacing="0" cellpadding="0" class="frame">
<tr>
<td><table width="100%" border="0" cellpadding="10" cellspacing="0">
<tr>
<td width="150" class="fieldarea">First Name</td>
<td><input type="text" name="firstname" size="30" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Last Name</td>
<td><input type="text" name="lastname" size="30" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Company Name</td>
<td><input type="text" name="companyname" size="30" value="" /></td>
</tr>
<tr>
<td class="fieldarea">Email Address</td>
<td><input type="text" name="email" size="50" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Address 1</td>
<td><input type="text" name="address1" size="40" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Address 2</td>
<td><input type="text" name="address2" size="30" value="" /></td>
</tr>
<tr>
<td class="fieldarea">City</td>
<td><input type="text" name="city" size="30" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">State/Region</td>
<td><input type="text" name="state" size="25" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Zip Code</td>
<td><input type="text" name="postcode" size="10" value="" />
*</td>
</tr>
<tr>
<td class="fieldarea">Country</td>
<td><select name="country"><option value="AF">Afghanistan</option><option value="AX">Aland Islands</option><option value="AL">Albania</option><option value="DZ">Algeria</option><option value="AS">American Samoa</option><option value="AD">Andorra</option><option value="AO">Angola</option><option value="AI">Anguilla</option><option value="AQ">Antarctica</option><option value="AG">Antigua And Barbuda</option><option value="AR">Argentina</option><option value="AM">Armenia</option><option value="AW">Aruba</option><option value="AU">Australia</option><option value="AT">Austria</option><option value="AZ">Azerbaijan</option><option value="BS">Bahamas</option><option value="BH">Bahrain</option><option value="BD">Bangladesh</option><option value="BB">Barbados</option><option value="BY">Belarus</option><option value="BE">Belgium</option><option value="BZ">Belize</option><option value="BJ">Benin</option><option value="BM">Bermuda</option><option value="BT">Bhutan</option><option value="BO">Bolivia</option><option value="BA">Bosnia And Herzegovina</option><option value="BW">Botswana</option><option value="BV">Bouvet Island</option><option value="BR">Brazil</option><option value="IO">British Indian Ocean Territory</option><option value="BN">Brunei Darussalam</option><option value="BG">Bulgaria</option><option value="BF">Burkina Faso</option><option value="BI">Burundi</option><option value="KH">Cambodia</option><option value="CM">Cameroon</option><option value="CA">Canada</option><option value="CV">Cape Verde</option><option value="KY">Cayman Islands</option><option value="CF">Central African Republic</option><option value="TD">Chad</option><option value="CL">Chile</option><option value="CN">China</option><option value="CX">Christmas Island</option><option value="CC">Cocos (Keeling) Islands</option><option value="CO">Colombia</option><option value="KM">Comoros</option><option value="CG">Congo</option><option value="CD">Congo, Democratic Republic</option><option value="CK">Cook Islands</option><option value="CR">Costa Rica</option><option value="CI">Cote D'Ivoire</option><option value="HR">Croatia</option><option value="CU">Cuba</option><option value="CY">Cyprus</option><option value="CZ">Czech Republic</option><option value="DK">Denmark</option><option value="DJ">Djibouti</option><option value="DM">Dominica</option><option value="DO">Dominican Republic</option><option value="EC">Ecuador</option><option value="EG">Egypt</option><option value="SV">El Salvador</option><option value="GQ">Equatorial Guinea</option><option value="ER">Eritrea</option><option value="EE">Estonia</option><option value="ET">Ethiopia</option><option value="FK">Falkland Islands (Malvinas)</option><option value="FO">Faroe Islands</option><option value="FJ">Fiji</option><option value="FI">Finland</option><option value="FR">France</option><option value="GF">French Guiana</option><option value="PF">French Polynesia</option><option value="TF">French Southern Territories</option><option value="GA">Gabon</option><option value="GM">Gambia</option><option value="GE">Georgia</option><option value="DE">Germany</option><option value="GH">Ghana</option><option value="GI">Gibraltar</option><option value="GR">Greece</option><option value="GL">Greenland</option><option value="GD">Grenada</option><option value="GP">Guadeloupe</option><option value="GU">Guam</option><option value="GT">Guatemala</option><option value="GG">Guernsey</option><option value="GN">Guinea</option><option value="GW">Guinea-Bissau</option><option value="GY">Guyana</option><option value="HT">Haiti</option><option value="HM">Heard Island & Mcdonald Islands</option><option value="VA">Holy See (Vatican City State)</option><option value="HN">Honduras</option><option value="HK">Hong Kong</option><option value="HU">Hungary</option><option value="IS">Iceland</option><option value="IN">India</option><option value="ID">Indonesia</option><option value="IR">Iran, Islamic Republic Of</option><option value="IQ">Iraq</option><option value="IE">Ireland</option><option value="IM">Isle Of Man</option><option value="IL">Israel</option><option value="IT">Italy</option><option value="JM">Jamaica</option><option value="JP">Japan</option><option value="JE">Jersey</option><option value="JO">Jordan</option><option value="KZ">Kazakhstan</option><option value="KE">Kenya</option><option value="KI">Kiribati</option><option value="KR">Korea</option><option value="KW">Kuwait</option><option value="KG">Kyrgyzstan</option><option value="LA">Lao People's Democratic Republic</option><option value="LV">Latvia</option><option value="LB">Lebanon</option><option value="LS">Lesotho</option><option value="LR">Liberia</option><option value="LY">Libyan Arab Jamahiriya</option><option value="LI">Liechtenstein</option><option value="LT">Lithuania</option><option value="LU">Luxembourg</option><option value="MO">Macao</option><option value="MK">Macedonia</option><option value="MG">Madagascar</option><option value="MW">Malawi</option><option value="MY">Malaysia</option><option value="MV">Maldives</option><option value="ML">Mali</option><option value="MT">Malta</option><option value="MH">Marshall Islands</option><option value="MQ">Martinique</option><option value="MR">Mauritania</option><option value="MU">Mauritius</option><option value="YT">Mayotte</option><option value="MX">Mexico</option><option value="FM">Micronesia, Federated States Of</option><option value="MD">Moldova</option><option value="MC">Monaco</option><option value="MN">Mongolia</option><option value="ME">Montenegro</option><option value="MS">Montserrat</option><option value="MA">Morocco</option><option value="MZ">Mozambique</option><option value="MM">Myanmar</option><option value="NA">Namibia</option><option value="NR">Nauru</option><option value="NP">Nepal</option><option value="NL">Netherlands</option><option value="AN">Netherlands Antilles</option><option value="NC">New Caledonia</option><option value="NZ">New Zealand</option><option value="NI">Nicaragua</option><option value="NE">Niger</option><option value="NG">Nigeria</option><option value="NU">Niue</option><option value="NF">Norfolk Island</option><option value="MP">Northern Mariana Islands</option><option value="NO">Norway</option><option value="OM">Oman</option><option value="PK">Pakistan</option><option value="PW">Palau</option><option value="PS">Palestinian Territory, Occupied</option><option value="PA">Panama</option><option value="PG">Papua New Guinea</option><option value="PY">Paraguay</option><option value="PE">Peru</option><option value="PH">Philippines</option><option value="PN">Pitcairn</option><option value="PL">Poland</option><option value="PT">Portugal</option><option value="PR">Puerto Rico</option><option value="QA">Qatar</option><option value="RE">Reunion</option><option value="RO">Romania</option><option value="RU">Russian Federation</option><option value="RW">Rwanda</option><option value="BL">Saint Barthelemy</option><option value="SH">Saint Helena</option><option value="KN">Saint Kitts And Nevis</option><option value="LC">Saint Lucia</option><option value="MF">Saint Martin</option><option value="PM">Saint Pierre And Miquelon</option><option value="VC">Saint Vincent And Grenadines</option><option value="WS">Samoa</option><option value="SM">San Marino</option><option value="ST">Sao Tome And Principe</option><option value="SA">Saudi Arabia</option><option value="SN">Senegal</option><option value="RS">Serbia</option><option value="SC">Seychelles</option><option value="SL">Sierra Leone</option><option value="SG">Singapore</option><option value="SK">Slovakia</option><option value="SI">Slovenia</option><option value="SB">Solomon Islands</option><option value="SO">Somalia</option><option value="ZA">South Africa</option><option value="GS">South Georgia And Sandwich Isl.</option><option value="ES">Spain</option><option value="LK">Sri Lanka</option><option value="SD">Sudan</option><option value="SR">Suriname</option><option value="SJ">Svalbard And Jan Mayen</option><option value="SZ">Swaziland</option><option value="SE">Sweden</option><option value="CH">Switzerland</option><option value="SY">Syrian Arab Republic</option><option value="TW">Taiwan</option><option value="TJ">Tajikistan</option><option value="TZ">Tanzania</option><option value="TH">Thailand</option><option value="TL">Timor-Leste</option><option value="TG">Togo</option><option value="TK">Tokelau</option><option value="TO">Tonga</option><option value="TT">Trinidad And Tobago</option><option value="TN">Tunisia</option><option value="TR">Turkey</option><option value="TM">Turkmenistan</option><option value="TC">Turks And Caicos Islands</option><option value="TV">Tuvalu</option><option value="UG">Uganda</option><option value="UA">Ukraine</option><option value="AE">United Arab Emirates</option><option value="GB">United Kingdom</option><option value="US" selected="selected">United States</option><option value="UM">United States Outlying Islands</option><option value="UY">Uruguay</option><option value="UZ">Uzbekistan</option><option value="VU">Vanuatu</option><option value="VE">Venezuela</option><option value="VN">Viet Nam</option><option value="VG">Virgin Islands, British</option><option value="VI">Virgin Islands, U.S.</option><option value="WF">Wallis And Futuna</option><option value="EH">Western Sahara</option><option value="YE">Yemen</option><option value="ZM">Zambia</option><option value="ZW">Zimbabwe</option></select>
*</td>
</tr>
<tr>
<td class="fieldarea">Phone Number</td>
<td><input type="text" name="phonenumber" size="20" value="" />
*</td>
</tr>
</table></td>
</tr>
</table>
<br />
<table width="100%" cellspacing="0" cellpadding="0" class="frame">
<tr>
<td><table width="100%" border="0" cellpadding="10" cellspacing="0">
<tr>
<td class="fieldarea">Please choose a security question</td>
<td><select name="securityqid">
<option value="12">Where were you born?</option>
<option value="5">What was your childhood nickname? </option>
<option value="6">In what city or town was your first job?</option>
<option value="7">What are the last 5 digits of your driver's license number?</option>
<option value="8">What is your first dog's name?</option>
<option value="9">What is your mother's maiden name?</option>
<option value="10">Who is your favorite musician?</option>
<option value="11">What are the last 4 digits of your credit card number?</option>
</select>
*</td>
</tr>
<tr>
<td class="fieldarea">Please enter an answer</td>
<td><input type="password" name="securityqans" size="30" /> *</td>
</tr>
<tr>
<td class="fieldarea">Your Website</td>
<td><input type="text" size="30" name="customfield[1]" value=""> </td>
</tr>
<tr>
<td class="fieldarea">How did you hear about us?</td>
<td><select name="customfield[7]"><option value="-">-</option><option value="Google">Google</option><option value=" Realtor Magazine"> Realtor Magazine</option><option value=" Friend/Colleague"> Friend/Colleague</option><option value=" Newspaper"> Newspaper</option><option value=" Magazine"> Magazine</option><option value=" Email"> Email</option><option value=" Affiliate"> Affiliate</option><option value=" Radio"> Radio</option><option value=" TV"> TV</option><option value=" Trade Show"> Trade Show</option><option value=" Other"> Other</option></select>
* </td>
</tr>
<tr>
<td class="fieldarea">Mobile Phone Number</td>
<td><input type="text" size="30" name="customfield[13]" value=""> </td>
</tr>
<tr>
<td class="fieldarea">What is your primary marketing plan?</td>
<td><select name="customfield[14]"><option value="" selected></option><option value="Pay Per Click">Pay Per Click</option><option value=" My own website"> My own website</option><option value=" Search Engine Optimization"> Search Engine Optimization</option><option value=" Locally"> Locally</option><option value=" TV"> TV</option><option value=" Radio"> Radio</option><option value=" Print"> Print</option><option value=" E-Mail"> E-Mail</option><option value=" Other"> Other</option></select>
* </td>
</tr>
<tr>
<td valign="top" class="fieldarea"><p>Describe your marketing plan</p></td>
<td><textarea name="customfield[15]" cols="60" rows="6"></textarea>
* </td>
</tr>
<tr>
<td class="fieldarea">Social Security Number</td>
<td><input type="text" size="30" name="customfield[16]" value=""> <br />
You may leave this blank but you will need to provide it before we can send your first payment</td>
</tr>
<tr>
</table></td>
</tr>
</table>
</form>