[[static_erefill_header.html]]


<!-- Content Area Start -->
<form id="frm" name="frm" method="post" action="registerstore2.php">
      <table border="0" width="100" cellspacing="2" cellpadding="2">


  <tr>
<td colspan="3" class="pad-lefta blue-txta"><h1>Store Registration Form -- Fill in below and click Submit</h1><br /></td>
</tr> 


<tr>
  <td class="pad-lefta blue-txta">Store Name </td>
  <td class="pad-lefta blue-txta"> <input type="text" name="storename" id="storename" size="80" maxlength="100" tabindex="1"></td>

</tr>


<tr>
  <td class="pad-lefta blue-txta">Address</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="address" id="address" size="100" maxlength="100" tabindex="2"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">City</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="city" id="city" size="50" maxlength="50" tabindex="3"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Province</td> 
     <td class="pad-lefta blue-txta">  
          <select name="province" tabindex="4">
               <option value="ON">Ontario</option>
               <option value="AB">Alberta</option>
               <option value="BC">British Columbia</option>
               <option value="MB">Manitoba</option>
               <option value="SK">Saskatchewan</option>
               <option value="PE">Prince Edward Island</option>
               <option value="NS">Nova Scotia</option>
               <option value="NB">New Brunswick</option>
               <option value="NF">NewFoundLand/Labrador</option>
           </select>
      </td>  
</tr>

<tr>
  <td class="pad-lefta blue-txta">Postal Code</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="postal" id="postal" size="10" maxlength="10" tabindex="5"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Contact Name</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="contactname" id="contactname" size="100" maxlength="100" tabindex="6"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Phone Number</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="phone" id="phone" size="20" maxlength="20" tabindex="7"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Fax Number</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="fax" id="fax" size="20" maxlength="20" tabindex="8"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Email</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="email" id="email" size="50" maxlength="50" tabindex="9"></td>
</tr>


<tr>
  <td class="pad-lefta blue-txta">Dispensary Software:</td>
  <td class="pad-lefta blue-txta">  
          <select name="dispensarysoftware" tabindex="10">
               <option value="Nexxsys">Nexxsys</option>
               <option value="Kroll">Kroll</option>
               <option value="Fillware">Fillware</option>
               <option value="Flexipharm">Flexipharm</option>
           </select>
      </td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">efttransit</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="efttransit" id="efttransit" size="9" maxlength="9" tabindex="11"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">eftaccountnumber</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="eftaccountnumber" id="eftaccountnumber" size="12" maxlength="12" tabindex="12"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">eftpayor</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="eftpayor" id="eftpayor" size="23" maxlength="23" tabindex="13"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Store Hours</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="hoursofoperation" id="eftpayor" size="100" maxlength="100" tabindex="14"></td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Central Profile Package:</td>
  <td class="pad-lefta blue-txta">
          <select name="cppackage" tabindex="15">
               <option value="None">None</option>
               <option value="Basic">Basic</option>
               <option value="Advanced">Advanced</option>
           </select>
      </td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Add On Module:Nursing Home:</td>
  <td class="pad-lefta blue-txta">
          <select name="cpnursinghome" tabindex="16">
               <option value="N">No</option>
               <option value="Y">Yes</option>
           </select>
      </td>
</tr>

<tr>
  <td class="pad-lefta blue-txta">Add On Module:Couponing:</td>
  <td class="pad-lefta blue-txta">
          <select name="cpcouponing" tabindex="17">
               <option value="N">No</option>
               <option value="Y">Yes</option>
           </select>
      </td>
</tr>


<tr>
  <td class="pad-lefta blue-txta">Website:</td>
  <td class="pad-lefta blue-txta">
          <select name="cphavewebsite" tabindex="18">
               <option value="N">None</option>
               <option value="Y">I have a Website</option>
               <option value="Need">I am interested in having a website</option>
           </select>
      </td>
</tr>
<tr>
  <td class="pad-lefta blue-txta">My website url is:</td>
  <td class="pad-lefta blue-txta"> <input type="text" name="cpwebsiteurl" id="cpwebsiteurl" size="100" maxlength="100" tabindex="19"></td>
</tr>



<tr>
  <td class="pad-lefta blue-txta">Banner:</td>
  <td class="pad-lefta blue-txta">
          <select name="bannerid" tabindex="20">
               <option value="1">No Banner</option>
               <option value="10">Allied Pharmacists</option>
               <option value="6">Guardian</option>
               <option value="2">IDA</option>
               <option value="4">Lovell</option>
               <option value="13">Medicine Shoppe</option>
               <option value="9">OnPharm</option>
               <option value="7">Pharmachoice</option>
               <option value="12">PharmPlus\Rexall</option>
               <option value="5">Pharmasave</option>
               <option value="11">Remedys</option>
               <option value="8">Total Health</option>



           </select>
      </td>
</tr>



<tr>
  <td class="pad-lefta blue-txta">&nbsp;</td>
  <td class="pad-lefta blue-txta"><input type="submit" name="submitBtn" id="submitBtn" value="Submit" tabindex="25"></td>
</tr> 

    

</table>
<!-- Content Area End -->
   </td>
  
</tr>
  <tr>
    <td width="100%" class="row3" colspan="2">
    
</form>

    
[[static_footer.html]]