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<?php $title = $_SITE_NAME." : Order Page"; ?>
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cc_fname:"First Name",
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// Credit Card Validation Javascript
// copyright 12th May 2003, by Stephen Chapman, Felgall Pty Ltd
// You have permission to copy and use this javascript provided that
// the content of the script is not changed in any way.
function validateCreditCard(s) {
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return (c%10 == 0);
}
function verify(f)
{
// Taken from "Javascript: The Definitive Guide" pg. 264.
// Modified heavily to suit our needs
// Loop through each element of the form and validate each item
//
// Set the parameters for each field to be valid
// If a field doesn't have any modifiers it is assumed to be
// a text field that can not be blank.
f.cc_phonearea.requiredlength = 3;
f.cc_phonearea.numeric = true;
f.cc_phoneprefix.requiredlength = 3;
f.cc_phoneprefix.numeric = true;
f.cc_phoneextension.requiredlength = 4;
f.cc_phoneextension.numeric = true;
f.cc_zip.requiredlength = 5;
f.cc_zip.numeric = true;
f.cc_state.requiredlength = 2;
f.cc_num.numeric = true;
f.cc_month.requiredlength = 2;
f.cc_month.numeric = true;
f.cc_year.requiredlength = 4;
f.cc_year.numeric = true;
f.cc_cvv.numeric = true;
var msg;
var empty_fields = "";
var errors = "";
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{
var element = f.elements[i];
//document.getElementById('errorconsole').innerHTML += element.name + ":" + element.type + "<br>";
if (element.type == 'text')
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if ( (element.value == null || element.value == "") || isblank(element.value) )
{
empty_fields += "\n " + prettynames[element.name];
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{
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}
if (!empty_fields && !errors) {
make_internal_popup('We are creating your account. Please Wait.');
return true;
}
msg = "__________________________________\n\n";
msg += "The form was not submitted because of the following error(s).\n";
msg += "Please correct these error(s) and re-submit.\n";
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if (errors) { msg += "\n"; }
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msg += errors;
alert(msg);
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$(document).ready(function(){
$('.tableform .gender input:radio').css('visibility','hidden');
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$(this).parent().find('label').removeClass('radio-focus');
$(this).addClass('radio-focus');
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if($(this).val().length==5) {
var str = "zip="+$(this).val();
$.ajax
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cache: false,
type: "POST",
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url: "/php/ZipToCity.php",
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$('#id-cc-city').val(data.city);
$('#id-cc-state').val(data.state);
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function billing_same_as_street_addressf(me) {
if($(me).is(':checked')) {
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<style>
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width:100%;
border-collapse: collapse;
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border-radius: 10px;
-webkit-box-shadow: 0 2px 10px #4cb0de;
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-moz-box-shadow: 0 2px 10px #4cb0de;
box-shadow: 0 2px 10px #4cb0de;
background: #fff;
background: rgba(255,255,255,0.8);
position:relative;
z-index:1;
padding-bottom:15px;
margin-bottom:15px;
}
.logoTop {
background:url("/lp2/assets/images/logo_768.png") no-repeat top center;
height:100px;
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.q { font-weight: bold; }
.a { padding-left: 10px!important }
#one_column {width:96%; margin:0 2%; padding:0}
.table_container {
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font:12px/120% verdana;
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width:35%;
padding: 7px 5px;
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background-repeat:no-repeat;
background-position:3px 1px;
border: 1px solid #0C76AC;
font-weight:bold;
margin-right:10px;
position: relative;
text-align:right;
cursor:pointer;
top:-7px;
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-->
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<link href="lp2/assets/css/responsive.css" type="text/css" rel="stylesheet" />
<!--INFO AREA + BOX MIDDLE-->
<div class="data">
<!--COLUMN-->
<div id="one_column" class="terms">
<div style="text-align:center;">
<h1>Step 2 of 3: Confirm your Answers & Complete Registration</h1>
<p>Here is the summary of the answers on step 1 of this Americas Got Funding registration process. Please confirm your answers to be sure they are correct and complete the last step at the bottom of the page. You are 1 step away from beginning the process of applying for funding of every kind if you qualify of course!!</p>
<?php if(!empty($_SESSION['prm'])) { ?>
<p class="text" style="color:#33aa66">Thanks to <?= $_SESSION['prm']['sid']; ?>, you can get access to these funding opportunities for only <span style='text-decoration:line-through'>$<?= $_INITIAL_FEE; ?></span> $<?= $_SESSION['prm']['initial']; ?>.</p>
<?php } ?>
<?php if(isset($error_message)) { ?>
<p style='margin:10px auto;width:90%;border:3px solid #FF0000'>
<center>
The following error has occurred:<br />
<em><?= ($error_message=='Address Verification does not match') ? 'Address Verification does not match.<br />Please be sure the ADDRESS and ZIP CODE match the BILLING address on your CREDIT CARD STATEMENT and enter it in again.' : $error_message;?></em><br />
If you need assistance, please call us at <?= $_SITE_PHONE;?>.
</center>
</p>
<?php } ?>
<form action="https://<?= $_SERVER['SERVER_NAME']; ?>/order.php" method="post" name="orderform" onsubmit="return verify(this);">
<center>
<div class="table_container">
<table class="tableform" width="100%">
<tr height="40">
<td valign="middle" colspan="3"><p class="tabletitle">Personal Information Summary</p></td>
</tr>
<tr>
<td class="q">First Name:</td>
<td class="a"><?= $cc_fname; ?><input type="hidden" name="cc_fname" value="<?= $cc_fname; ?>" /></td>
<td class="q">Last Name:</td>
<td class="a"><?= $cc_lname; ?><input type="hidden" name="cc_lname" value="<?= $cc_lname; ?>" /></td>
</tr>
<tr>
<td class="q">Zip:</td>
<td class="a"><?= $cc_zip; ?><input type="hidden" name="cc_zip" value="<?= $cc_zip; ?>" /></td>
<td class="q">State:</td>
<td class="a"><?= $cc_state; ?><input type="hidden" name="cc_state" value="<?= $cc_state;?>" /></td>
</tr>
<tr>
<td class="q">City:</td>
<td class="a"><?= $cc_city; ?><input type="hidden" name="cc_city" value="<?= $cc_city; ?>" /></td>
<td class="q">Street Address:</td>
<td class="a"><?= $cc_addr; ?><input type="hidden" name="cc_addr" value="<?= $cc_addr; ?>" /></td>
</tr>
<tr>
<td class="q">Gender:</td>
<td class="a gender"><?= $app_gender; ?><input type="hidden" name="app_gender" value="<?= $app_gender;?>" /></td>
<td class="q">What is<br />your age?</td>
<td class="a"><?= $app_age; ?><input type="hidden" name="app_age" value="<?= $app_age;?>" /></td>
</tr>
<tr>
<td class="q">Day Phone:</td>
<td class="a">
<?= $cc_phonearea; ?>-<?= $cc_phoneprefix; ?>-<?= $cc_phoneextension; ?>
<input type="hidden" name="cc_phonearea" value="<?= $cc_phonearea; ?>" />
<input type="hidden" name="cc_phoneprefix" value="<?= $cc_phoneprefix; ?>" />
<input type="hidden" name="cc_phoneextension" value="<?= $cc_phoneextension; ?>" />
</td>
<td colspan="2" class="q"> </td>
</tr>
</table>
</div>
</center>
<center>
<div class="table_container">
<table class="tableform" width="100%">
<tr height="40">
<td valign="middle" colspan="3"><p class="tabletitle">Application Question Summary</p></td>
</tr>
<tr>
<td class="q">Citizenship Status:</td>
<td class="a"><?= $app_citizenship; ?></td>
</tr>
<?
if(!empty($types_of_grants)) {
?>
<tr>
<td class="q" colspan="2">Types of funding areas you are interested in?</td>
</tr>
<tr>
<?
$counter = 0;
foreach ($types_of_grants as $grant)
{
echo "<td class=\"a\">$grant</td>";
$counter++;
if ($counter % 2 == 0)
{
echo "</tr><tr>";
}
}
?>
</tr>
<?
}
?>
<tr>
<td class="q">How much money do you need?</td>
<td class="a"><?= $app_amount_needed; ?></td>
</tr>
<tr>
<td class="q" colspan="2">Describe what you will use the money for:</td>
</tr>
<tr>
<td class="a" colspan="2"><p><?= stripslashes($app_usedescription); ?></p></td>
</tr>
<tr>
<td class="q" colspan="2">What unique things would separate you from other applicants applying for this money?</td>
</tr>
<tr>
<td class="a" colspan="2"><p><? echo stripslashes($app_uniqueness); ?></p></td>
</tr>
</table>
</div>
</center>
<center>
<div class="table_container">
<table class="tableform" width="100%">
<tr height="40">
<td valign="middle" colspan="3"><p class="tabletitle">User Account Info</p></td>
</tr>
<tr>
<td class="q">Username for Online Americas Got Funding:</td>
<td class="a"><?= $cc_email; ?><input type="hidden" name="cc_email" value="<?= $cc_email; ?>" /></td>
</tr>
<tr>
<td class="s">
<i>** The Website and Password for the Members site will be given to you at the completion of the registration process</i>
</td>
</tr>
</table>
</div>
</center>
<center>
<style type="text/css">
div#research_div { color:#333; margin:10px auto; text-align:left; height:300px; border:1px solid cccccc; padding:10px; overflow:auto; }
div#research_text { width:100%; }
#research_text p { margin:10px 0px}
div#research_text ul li { color:#B32317; font-size:17px; line-height:1.6em; margin-left:30px}
.research_term { font-weight:bold; }
.research_red { color:#B32317; font:bold 18pt/120% verdana; }
.research_blue { color:#002D56; font:bold 16pt/120% verdana; }
.research_blue_sm { color:#002D56; font:bold 13pt/120% verdana; }
</style>
<div class="table_container">
<table class="tableform" width="100%">
<tr height="40">
<td valign="middle" colspan="3"><p class="tabletitle">Payment Information for the <?= (!empty($_SESSION['prm'])) ? '<span style="text-decoration:line-through">$'.$_INITIAL_FEE.'</span> <span style="color:#33aa66">$'.$_SESSION['prm']['initial'].'</span>' : '$'.$_INITIAL_FEE; ?> Access Fee</p></td>
</tr>
<tr>
<td colspan="3">
<p class="a">Our accountant tells us we have to charge a registration fee to help pay for the internet advertising we have
to do to get this information out to you and to cover administration expenses. <strong>So we have settled on <?= (!empty($_SESSION['prm'])) ? '<span style="text-decoration:line-through">$'.$_INITIAL_FEE.'</span> <span style="color:#33aa66">$'.$_SESSION['prm']['initial'].'</span>' : '$'.$_INITIAL_FEE; ?>,</strong>
which we feel is a fair price to pay for such valuable information, which is updated on a regular basis. You will have access
to the applications and training through the Americas Got Funding site. <?php if(!empty($_SESSION['prm'])) { ?> By ordering today you understand that you are enrolling into the Exclusive Funding Applications Membership Resource Center where we provide you application resources for hundreds of different funding options. Your access to the site will automatically be renewed each month for the same monthly fee above unless you cancel with us.
You understand that this consumer transaction involves a negative option, and that you may be liable for payment of future payment of future goods and services under the terms of this agreement if I fail to notify the supplier not to supply the goods or services described. <?php } ?><strong>WE ALSO HAVE A GUARANTEE. <u>If you don't qualify for a Free Funding Program,
you will be refunded immediately.</u></strong> Just provide us with the funding application you applied for and the response letter from the
funder. <strong>So, you qualify for a funding program or you will have your payment refunded to you!</strong></p>
<?php if(!empty($_SESSION['prm'])) { ?>
<div id="research_div" style="border:1px solid grey; height: 200px; padding:2px; overflow:auto; margin: 5px;">
<p class="research_term">APPLICATION RESEARCH SERVICE TERMS OF USE</p>
<p class="research_term">YOU UNDERSTAND THAT THIS CONSUMER TRANSACTION INVOLVES A NEGATIVE OPTION, AND THAT YOU MAY BE LIABLE FOR PAYMENT OF FUTURE GOODS AND SERVICES UNDER THE TERMS OF THIS AGREEMENT IF I FAIL TO NOTIFY THE SUPPLIER NOT TO SUPPLY THE GOODS OR SERVICES DESCRIBED.</p>
<p>This Terms of Use Agreement sets forth the standards of use of the <?=$_SITE_NAME;?> Online Service. By using the <?=$_SERVER['SERVER_NAME'];?> Website (may be herein referred to as 'site'), you (the "Member") agree to these terms and conditions. If you do not agree to these terms and conditions, you should immediately discontinue usage of this Website. We reserve the right to modify, alter, or update the terms and conditions of this agreement at any time and without prior notice. Modifications shall become effective immediately upon being posted on the Website. Your use of the Service after amendments are posted constitutes an acceptance of the Agreement and its modifications. This Agreement may not be amended, except as provided in this paragraph.</p>
<p><span class="research_term">Funding Application Research Service</span><br />
<?= $_SITE_NAME;?> provides Members an option to opt-in for a Funding Application Research Service. This service is completely optional and offered to clients after they purchase. When they user opts-in for this service, our research team will research new funding opportunities on the internet as they become available and offer them in one place on the site for them to review the ones that they potentially could qualify for if they meet the funders criteria. By agreeing to this service, the user agrees to a membership fee of $<?= number_format($monthly_subscription_fee,2); ?> per month which is waived for the first <?= $monthly_subscription_trial; ?> days. If the client does not cancel the service, they will be charged $<?= number_format($monthly_subscription_fee,2); ?> each month for this ongoing service. They can cancel at anytime by calling our toll free number <?= $_SITE_PHONE; ?> or by emailing us using our <a target="_blank" href="contact.php">online form on our contact us page</a>.</p>
<p><span class="research_term">Description of Service</span><br />
<?=$_SITE_NAME;?> (may be herein referred to as 'Company,' 'we,' 'us,' and 'our,') provides Members with a web-based resource center, offering education materials on how to find and apply for funding. Company is not a funding agency and does not give away money.</p>
<p><span class="research_term">Service Modifications or Interruption</span><br />
Company reserves the right to modify or discontinue provision of the Website and its Service, either temporarily or permanently, at any time, with or without notice and without liability towards Member. Member acknowledges and accepts that Company does not guarantee continuous, uninterrupted or secure access to our Website and operation of our Website may be interfered with or adversely affected by numerous factors or circumstances outside of our control.</p>
<p><span class="research_term">Registration</span><br />
Upon registration with our site, you will be given a username and password for access to our Web-based Resource Center. You will be charged a initial fee of $<?= number_format($initial_subscription_fee,2); ?> for said access. If you have any questions you can email us at any time at <?=$_SITE_EMAIL;?> or calling us on our toll free number: 888-261-4837. The charges on your credit card will appear as USA Grants.</p>
<p>WE ALSO HAVE A GUARANTEE: IF YOU DON'T QUALIFY FOR A FUNDING PROGRAM, YOU WILL BE REFUNDED THE $<?= number_format($initial_subscription_fee,2); ?> AMOUNT PAID. All that is required is you provide our support team with the funding application you applied for and the response letter from the funding program by email or mail. By registering on our site, you authorize Company to charge your credit card the above-described fee.</p>
<p><span class="research_term">Disclaimer of Warranties</span><br />
The site is provided on an "as is" and on an "as available" basis. To the fullest extent permitted by applicable law, Company makes no representations or warranties of any kind, express or implied, regarding the use or the results of this Website in terms of its correctness, accuracy, or reliability. <?=$_SITE_NAME;?> also makes no guarantees that the client will receive funding of any kind.</p>
<p><?=$_SITE_NAME;?> shall have no liability for any interruptions in the use of this Website. Company disclaims all warranties with regard to the information provided, including the implied warranties of merchantability and fitness for a particular purpose, and non-infringement. This aforementioned exclusion is inapplicable in those jurisdictions which do not allow the exclusion of implied warranties.</p>
<p><span class="research_term">Limitation of Liability</span><br />
Company shall not be liable for any damages whatsoever, and in particular, Company shall not be liable for any special, indirect, consequential, or incidental damages, or damages for lost profits, loss of revenue, or loss of use, arising out of or related to this Website or the information contained in it, whether such damages arise in contract, negligence, tort, under statute, in equity, at law, or otherwise, even if Company has been advised of the possibility of such damages. Some or all of the above-referenced limitation may be inapplicable in jurisdictions that do not allow for the limitation or exclusion of liability for incidental or consequential damages.</p>
<p>You agree, by submitting your order for the Membership to <?=$_SERVER['SERVER_NAME'];?>, that the Company's maximum liability is limited to the total amount paid by you, regardless of extenuating circumstances. If you have any concern regarding the products or services, you must elect to not order from this Website. By ordering from this Website you certify that you have been notified of this limitation of liability and agree with it.</p>
<p><span class="research_term">Indemnification</span><br />
Member agrees to indemnify and hold blameless <?=$_SITE_NAME;?>, its parents, subsidiaries, affiliates, officers and employees, from any claim or demand, including reasonable attorneys' fees and costs, made by any third party due to or arising out of Member's use of the Service, the violation of this Agreement, or infringement by Member, or other user of the Service using Member's computer, of any intellectual property or any other right of any person or entity.</p>
<p><span class="research_term">Third Parties</span><br />
Our Website may include links to other sites on the internet that are owned and operated by online merchants and other third parties. You agree that our Company will not in any way be liable or responsible for your dealings or interaction with third parties. You should contact the site administrator or webmaster for those third-party sites if you have any concerns regarding such links or the content located on such sites. Your use of those third-party sites is subject to the terms of use and privacy policies of each site. We encourage all Members to review said policies of third-parties' sites.</p>
<p><span class="research_term">Disclaimer Regarding Vendors</span><br />
Product specifications and other information have either been provided by the Vendors or collected from publicly-available sources. While <?=$_SITE_NAME;?> makes every effort to ensure that the information on this Website is accurate, we can make no representations or warranties as to the accuracy or reliability of any information provided on this Website.</p>
<p>Company makes no warranties or representations whatsoever with regard to any product provided or offered by any Vendor, and you acknowledge that any reliance on representations and warranties provided by any Vendor shall be at your own risk.</p>
<p><span class="research_term">Governing Jurisdiction</span><br />
Our Website is operated and provided in the State of Delaware. As such, we are subject to the laws of the State Delaware, and such laws will govern this Terms of Use Agreement, without giving effect to any choice of law rules. We make no representation that our Website or other services are appropriate, legal, or available for use in other locations. Accordingly, if you choose to access our site, you agree to do so subject to the internal laws of the State Delaware.</p>
<p><span class="research_term">Legal Compliance</span><br />
Member may not use the Service in any way that violates applicable state, federal, or international laws, regulations or other requirements. Member assumes all knowledge of applicable law and is responsible for compliance with any such laws. Member further agrees not to transmit any material that encourages conduct that could constitute a criminal offense, give rise to civil liability or otherwise violate any applicable local, state, national, or international law or regulation.</p>
<p><span class="research_term">Copyright and Trademark Information</span><br />
All content included or available on this site, including site design, text, graphics, interfaces, and the selection and arrangements thereof is ©2009 <?=$_SITE_NAME;?>, with all rights reserved, or is the property of <?=$_SITE_NAME;?> and/or third parties protected by intellectual property rights. Any use of materials on the Website, including reproduction for purposes other than those noted above, modification, distribution, or replication, any form of data extraction or data mining, or other commercial exploitation of any kind, without prior written permission of an authorized officer of Company, is strictly prohibited. Members agree that they will not use any robot, spider, or other automatic device, or manual process to monitor or copy our web pages or the content contained therein without prior written permission of an authorized officer of Company.</p>
<p>Company trademarks may not be used in connection with any product or service that is not provided by <?=$_SITE_NAME;?> in any manner that is likely to cause confusion among customers, or in any manner that disparages or discredits Company.</p>
<p>All other trademarks displayed on the Website are the trademarks of their respective owners, and constitute neither an endorsement nor a recommendation of those Vendors. In addition, such use of trademarks or links to the web sites of Vendors is not intended to imply, directly or indirectly, that those Vendors endorse or have any affiliation with Company.</p>
<p><span class="research_term">Copyright Infringement</span><br />
Pursuant to Section 512(c) of the Copyright Revision Act, as enacted through the Digital Millennium Copyright Act, <?=$_SITE_NAME;?> designates the following agent for receipt of notifications of claimed copyright infringement: <?=$_SITE_EMAIL;?>.</p>
<p><span class="research_term">Robot Networks</span><br />
Company retains the right, at its sole discretion, to terminate any accounts involved with botnets (robot networks) and related activities. If any hostnames are used as command and control points for botnets, Company reserves the right to direct the involved hostnames to a honeypot, loopback address, logging facility, or any other destination at our discretion.</p>
<p><span class="research_term">Other Terms</span><br />
If any provision of this Terms of Use Agreement shall be unlawful, void, or unenforceable for any reason, the other provisions (and any partially-enforceable provision) shall not be affected thereby and shall remain valid and enforceable to the maximum possible extent. You agree that this Terms of Use Agreement and any other agreements referenced herein may be assigned by Company, in our sole discretion, to a third party in the event of a merger or acquisition. This Terms of Use Agreement shall apply in addition to, and shall not be superseded by, any other written agreement between Company and Member in relation to your participation as a Member. Member agrees that by accepting this Terms of Use Agreement, Member is consenting to the collection and use of their personally identifiable information, and other practices, as outlined in our Privacy Policy Statement, as found on the Website.</p>
</div> <?php } ?>
</td>
</tr>
<tr>
<td class="q">Billing Information</td>
<td class="a"><label><input type="checkbox" value="1" id="billing_same_as_street_address" name="billing_same_as_street_address" onclick="billing_same_as_street_addressf(this);" /> Same as Street Address</label></td>
<td> </td>
</tr>
<tr>
<td class="q">Cardholder Name</td>
<td class="a"><input type="text" name="cardholder_name" id="cardholder_name" class="full" maxlength="128" value="<?= $cardholder_name;?>" /></td>
<td> </td>
</tr>
<tr>
<td class="q">Billing Address</td>
<td class="a"><input type="text" name="billing_street_address" id="billing_street_address" class="full" maxlength="64" value="<?= $billing_street_address;?>" /></td>
<td> </td>
</tr>
<tr>
<td class="q">City</td>
<td class="a"><input type="text" name="billing_city" id="billing_city" class="full" maxlength="64" value="<?= $billing_city;?>" /></td>
<td> </td>
</tr>
<tr>
<td class="q">State</td>
<td class="a"><input type="text" name="billing_state" id="billing_state" class="full" maxlength="2" value="<?= $billing_state;?>" /></td>
<td> </td>
</tr>
<tr>
<td class="q">Zip</td>
<td class="a"><input type="text" name="billing_zip" id="billing_zip" class="full" maxlength="5" value="<?= $billing_zip;?>" /></td>
<td> </td>
</tr>
<tr>
<td colspan="3"> </td>
</tr>
<tr>
<td class="q">Credit Card Number:</td>
<td class="a"><input type="tel" name="cc_num" size="20" maxlength="16" value="<?= ($cc_num != '') ? $cc_num : NULL; ?>" /></td>
<td>
<img src="/assets/images/credit_cards.png" />
</td>
</tr>
<tr>
<td class="q">Exp:</td>
<td>
<select name="cc_month">
<option value="MM">MM</option>
<?
for($i = 1; $i <= 12; $i++) {
$month = sprintf('%02s',$i);
$selected = (strcmp($month, $cc_month) == 0) ? "selected" : NULL;
echo "\n<option value='$month' $selected>$month</option>";
}
?>
</select>
<select name="cc_year">
<option value="YYYY">YYYY</option>
<?
$years = range(date('Y'), date('Y')+20);
foreach($years as $year) {
$selected = (strcmp($year, $cc_year) == 0) ? "selected" : NULL;
echo "\n<option value='$year' $selected>$year</option>";
}
?>
</select>
</td>
<td> </td>
</tr>
<tr>
<td class="q">3 Digit Verification Code<br />on back of Card:</td>
<td class="a"><input size=5 type="tel" maxlength="4" name="cc_cvv" value="<?php echo $cc_cvv ?>" /></td>
<td colspan="2"> </td>
</tr>
</table>
<input type="hidden" name="send_login_text" value="1" />
<input type="hidden" name="text_phone" value="<?= $cc_phonearea; ?>-<?= $cc_phoneprefix; ?>-<?= $cc_phoneextension; ?>" />
<?php
//No longer ask if they want a text, just send one
/*
<br />
<label><input type="checkbox" name="send_login_text" value="1" checked onclick="if($(this).is(':checked')) { $('#login_text_hidden_box').show(); } else { $('#login_text_hidden_box').hide(); }" /> Send login information in a text</label>
<div id="login_text_hidden_box" style="display:block;">
<label>Cell Phone: <input type="text" name="text_phone" value="<?= $cc_phonearea; ?>-<?= $cc_phoneprefix; ?>-<?= $cc_phoneextension; ?>" /></label>
</div>
*/ ?>
</div>
</center>
<div style="text-align:center;">
<input type="submit" value="CLICK HERE TO APPLY" />
<input type="hidden" name="submitted" value="submitted" />
<input type="hidden" name="cc_lead_id" value="<? echo $cc_lead_id; ?>" />
<input type="hidden" name="tc" value="<?= $tc; ?>" />
<?= $trackerformparams; ?>
<br /><br /><br />
</div>
</form>
</div> <!--end centered div-->
</div> <!--end one column-->
<div style="clear:both;"></div>
</div> <!--end info area-->
<img src="https://pcisecureform.com/lcapi/FormCCImpressionTracking.php?site=agf&lead_id=<?= $cc_lead_id;?>&form_url=<?= urlencode('/order_form.php');?>" />
<!--INCLUDE FOOTER-->
<?php include('assets/includes/footer.php'); ?>