Business/SOHO Order Information Billing Information [text First-Name 15/ class:NAME “First Name”] [text Last-name 15 class:NAME “Last Name”] [text company 35 “Company”] [text address 35 “Address”] [text City 10/15 class:CITY “City”] [select State 4/ class:STATE “AL” “AK” “AZ” “AR” “CA” “CO” “CT” “DE” “DC” “FL” “GA” “HI” “ID” “IL” “IN” “IA” “KS” “KY” “LA” “ME” “MD” “MA” “MI” “MN” “MS” “MO” “MT” “NE” “NV” “NH” “NJ” “NM” “NY” “NC” “ND” “OH” “OK” “OR” “PA” “RI” “SC” “SD” “TN” “TX” “UT” “VT” “VA” “WA” “WV” “WI” “WY”] [text Zip 5/5 class:ZIP “ZIP”] [text your-email 40/50 “example@example.com”] [text current-phone 11/12 “Phone Number”] Payment Information Card Holder Name [text CC-Name class:PAY 16/18] Card Number[text CC-Number class:PAY 16/18] Expiration [select ExpMonth class:PULLDOWN “Jan” “Feb” “Mar” “Apl” “May” “Jun” “Jul” “Aug” “Sep” “Oct” “Nov” “Dec”] [select ExpYear class:PULLDOWN “2014” “2015” “2016” “2017” “2018” “2019” “2020”] Security Code [text SecCode class:ZIP 3/4] Plan Selection [select PlanSelection “Business Volice SOHO – $24.95/mo”] Phone Number Information New Number [select New-Number class:YN “No” “Yes”] Request Number to be Ported [select Port-Number class:YN “No” “Yes”] Phone Number Information Current Phone Number [text phone-number class:PULLDOWN 11/12] Current Phone Provider [text provider class:PULLDOWN 10/15] Accept Terms of Service [select terms class:YN “Yes” “No”] [submit “Send”]
