<form method="post" action="order.php">

<!-- DO NOT change ANY of the php sections -->
<?php $ip = getenv("REMOTE_ADDR");
$httpref = getenv ("HTTP_REFERER");
$httpagent = getenv ("HTTP_USER_AGENT");
?>

                    <input name="ip" value="<?php echo $ip ?>" type="hidden">
                    <input name="httpref" value="<?php echo $httpref ?>" type="hidden">
                    <input name="httpagent" value="<?php echo $httpagent ?>" type="hidden">

    
                    <p>Full Name: <br>

    <input name="client" size="35" type="text"> (Require)<br>

    &nbsp;Email:<br>

    <input name="clientmail" size="35" type="text"> (Require)<br>

    Domain:<br>

    <input name="clientdomain" size="35" type="text"> (Require)<br>

    Address <br>

	<input name="clientaddress" size="35" type="text"> (Require)<br>

	&nbsp; <br>


    Phone: <br>

    <input name="clientphone" size="35" type="text"> (Require)<br>

    Promo Code: <br>

    <input name="clientpromo" size="35" type="text"> (Optional)<br>


    </p>
                    <p>Package :<br>

    &nbsp;
                    <select name="clientpackage" size="1">
                    <option value=" none ">Select your 'Private' Plan</option>
                    <option value=" Domain Registration ">'Private' Domain Registration RM35.00/year</option>
                    <option value=" Domain Transfer ">'Private' Domain Transfer RM30.00 1st year</option>
                    <option value=" Domain Renew ">'Private' Domain Renew RM35.00 /yearr</option>
                    <option value=" Private 1">'Private' Plan 1 RM99.99/yearr</option>
                    <option value=" Private 2">'Private' Plan 2 (Free Domain) RM189.99/year</option>
                    <option value=" Private 3">'Private' Plan 3 (Free Domain) RM279.99/year</option>
                    <option value=" Private 4">'Private' Plan 4 (Free Domain) RM369.99/year</option>
                    <option value=" Private 5">'Private' Plan 5 (Free Domain) RM459.99/year</option>
                    </select>
 <br>

    
    </p>
                    <p>Payment :<br>

    &nbsp;
                    <select name="clientpayment" size="1">
                    <option value=" none ">Select your 'Private' Payment Method</option>
                    <option value=" MayBank2u ">May Bank</option>
                    <option value=" Public Bank ">Public Bank</option>
                    <option value=" Paypal ">PayPal</option>
                    </select>


                </p>
                    <p> <br>

    
    &nbsp;Additional Comment: <br>

    &nbsp;<textarea name="clientcomment" rows="4" cols="34"></textarea> <br>

    &nbsp;<input value="'Private' Order" type="submit">

                </p>
                  </form>