[% PROCESS "header.tt" title => "Account Information" %]

<span style="color:green">Congratulations! The test domain <b>[% domain %]</b> is available.</span><br>

Please enter your account information.
<form name=[% form_name %] action=[% script_name %] method=post>
<input type=hidden name=domain>

<table>
<tr>
  <td><label>First Name:</label></td>
  <td><input type=text name=first_name></td>
  <td><span class=error id=first_name_error>[% first_name_error %]</span></td>
</tr>
<tr>
  <td><label>Last Name:</label></td>
  <td><input type=text name=last_name></td>
  <td><span class=error id=last_name_error>[% last_name_error %]</span></td>
</tr>
<tr>
  <td><label>Country:</label></td>
  <td>
    <select name=country>
      <option value="">Choose country</option>
      [%- FOR code IN countries.keys.sort %]
      <option value="[% code %]">[% countries.$code %]</option>
      [%- END %]
    </select>
  </td>
  <td><span class=error id=country_error>[% country_error %]</span></td>
</tr>
<tr>
  <td><label>Password:</label></td>
  <td><input type=text name=password></td>
  <td><span class=error id=password_error>[% password_error %]</span></td>
</tr>
<tr>
  <td><label>Password<br>Verify:</label></td>
  <td><input type=text name=password2></td>
  <td><span class=error id=password2_error>[% password2_error %]</span></td>
</tr>

<tr>
  <td colspan=2 align=right>
    <input type=submit value="Bill me"><br>
  </td>
  <td>&nbsp;</td>
</tr>
</table>

</form>
[% js_validation %]

[% PROCESS "footer.tt" %]