1 | <!--{*
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2 | * Copyright (c) 2000-2007 LOCKON CO.,LTD. All Rights Reserved.
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3 | *
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4 | * http://www.lockon.co.jp/
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5 | *}-->
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6 | <!--¢§CONTENTS-->
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7 | <table width="" border="0" cellspacing="0" cellpadding="0" summary=" ">
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8 | <tr>
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9 | <td align="center" bgcolor="#ffffff">
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10 | <!--¢§MAIN ONTENTS-->
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11 | <table width="700" border="0" cellspacing="0" cellpadding="0" summary=" ">
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12 | <tr>
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13 | <td><img src="<!--{$smarty.const.URL_DIR}-->img/mypage/title.jpg" width="700" height="40" alt="MY¥Ú¡¼¥¸"></td>
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14 | </tr>
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15 | <tr><td height="15"></td></tr>
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16 | </table>
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17 | <table width="700" border="0" cellspacing="0" cellpadding="0" summary=" ">
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18 | <tr valign="top">
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19 | <td>
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20 | <!--{include file=$tpl_navi}-->
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21 | </td>
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22 | <td align="right">
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23 | <table width="515" border="0" cellspacing="0" cellpadding="0" summary=" ">
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24 | <form name="form1" id="form1" method="post" action="<!--{$smarty.server.PHP_SELF|escape}-->">
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25 | <input type="hidden" name="mode" value="confirm">
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26 | <input type="hidden" name="customer_id" value="<!--{$arrForm.customer_id|escape}-->">
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27 | <tr>
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28 | <td><!--¡ú¥¿¥¤¥È¥ë--><img src="<!--{$smarty.const.URL_DIR}-->img/mypage/subtitle02.gif" width="515" height="32" alt="²ñ°÷ÅÐÏ¿ÆâÍÆÊѹ¹"></td>
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29 | </tr>
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30 | <tr><td height="15"></td></tr>
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31 | <tr>
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32 | <td class="fs12">²¼µ¹àÌܤˤ´ÆþÎϤ¯¤À¤µ¤¤¡£¡Ö<span class="red">¢¨</span>¡×°õ¤ÏÆþÎÏɬ¿Ü¹àÌܤǤ¹¡£<br>
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33 | ÆþÎϸ塢°ìÈÖ²¼¤Î¡Ö³Îǧ¥Ú¡¼¥¸¤Ø¡×¥Ü¥¿¥ó¤ò¥¯¥ê¥Ã¥¯¤·¤Æ¤¯¤À¤µ¤¤¡£</td>
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34 | </tr>
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35 | <tr><td height="10"></td></tr>
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36 | <tr>
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37 | <td bgcolor="#cccccc" align="center">
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38 | <!--ÆþÎÏ¥Õ¥©¡¼¥à¤³¤³¤«¤é-->
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39 | <table width="515" border="0" cellspacing="1" cellpadding="10" summary=" ">
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40 | <tr>
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41 | <td width="122" bgcolor="#f0f0f0" class="fs12n">¤ªÌ¾Á°<span class="red">¢¨</span></td>
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42 | <td width="350" bgcolor="#ffffff" class="fs12n"><span class="red"><!--{$arrErr.name01}--><!--{$arrErr.name02}--></span>
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43 | À« <input type="text" name="name01" value="<!--{$arrForm.name01}-->" maxlength="<!--{$smarty.const.STEXT_LEN}-->" style="<!--{$arrErr.name01|sfGetErrorColor}-->; ime-mode: active;" size="15" class="box15" />¡¡Ì¾ <input type="text" name="name02" value="<!--{$arrForm.name02}-->" maxlength="<!--{$smarty.const.STEXT_LEN}-->" style="<!--{$arrErr.name02|sfGetErrorColor}-->; ime-mode: active;" size="15" class="box15" />
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44 | </td>
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45 | </tr>
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46 | <tr>
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47 | <td bgcolor="#f0f0f0" class="fs12n">¤ªÌ¾Á°¡Ê¥Õ¥ê¥¬¥Ê¡Ë<span class="red">¢¨</span></td>
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48 | <td bgcolor="#ffffff" class="fs12n"><span class="red"><!--{$arrErr.kana01}--><!--{$arrErr.kana02}--></span>
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49 | ¥»¥¤ <input type="text" name="kana01" value="<!--{$arrForm.kana01}-->" maxlength="<!--{$smarty.const.STEXT_LEN}-->" style="<!--{$arrErr.kana01|sfGetErrorColor}-->; ime-mode: active;" size="15" class="box15" />¡¡¥á¥¤ <input type="text" name="kana02" value="<!--{$arrForm.kana02}-->" maxlength="<!--{$smarty.const.STEXT_LEN}-->" style="<!--{$arrErr.kana02|sfGetErrorColor}-->; ime-mode: active;" size="15" class="box15" /></td>
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50 | </tr>
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51 | <tr>
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52 | <td bgcolor="#f0f0f0" class="fs12n">͹ÊØÈÖ¹æ<span class="red">¢¨</span></td>
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53 | <td bgcolor="#ffffff">
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54 | <table border="0" cellspacing="0" cellpadding="0" summary=" ">
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55 | <tr>
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56 | <!--{assign var=key1 value="zip01"}-->
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57 | <!--{assign var=key2 value="zip02"}-->
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58 | <td colspan="2"><span class="fs12n"><span class="red"><!--{$arrErr[$key1]}--><!--{$arrErr[$key2]}--></span>
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59 | ¢© <input type="text" name="zip01" value="<!--{$arrForm.zip01}-->" maxlength="<!--{$smarty.const.ZIP01_LEN}-->" style="<!--{$arrErr.zip01|sfGetErrorColor}-->; ime-mode: disabled;" size=6 class="box6" /> - <input type="text" name="zip02" value="<!--{$arrForm.zip02}-->" maxlength="<!--{$smarty.const.ZIP02_LEN}-->" style="<!--{$arrErr.zip02|sfGetErrorColor}-->; ime-mode: disabled;" size=6 class="box6" />¡¡
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60 | <a href="http://search.post.japanpost.jp/7zip/" target="_blank"><span class="fs12">͹ÊØÈֹ渡º÷</span></a></td>
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61 | </tr>
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62 | <tr><td height="5"></td></tr>
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63 | <tr>
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64 | <td><a href="<!--{$smarty.const.URL_DIR}-->input_zip.php" onclick="fnCallAddress('<!--{$smarty.const.URL_INPUT_ZIP}-->', 'zip01', 'zip02', 'pref', 'addr01'); return false;" target="_blank"><img src="<!--{$smarty.const.URL_DIR}-->img/common/address.gif" width="86" height="20" alt="½»½ê¼«Æ°ÆþÎÏ" /></a></td>
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65 | <td class="fs10n"> ͹ÊØÈÖ¹æ¤òÆþÎϸ塢¥¯¥ê¥Ã¥¯¤·¤Æ¤¯¤À¤µ¤¤¡£</td>
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66 | </tr>
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67 | </table>
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68 | </td>
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69 | </tr>
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70 | <tr>
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71 | <td bgcolor="#f0f0f0" class="fs12">½»½ê<span class="red">¢¨</span></td>
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72 | <td bgcolor="#ffffff">
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73 | <table border="0" cellspacing="0" cellpadding="0" summary=" ">
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74 | <tr>
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75 | <td class="fs12n"><span class="red"><!--{$arrErr.pref}--><!--{$arrErr.addr01}--><!--{$arrErr.addr02}--></span>
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76 | <select name="pref" style="<!--{$arrErr.pref|sfGetErrorColor}-->">
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77 | <option value="" selected>ÅÔÆ»Éܸ©¤òÁªÂò</option>
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78 | <!--{html_options options=$arrPref selected=$arrForm.pref}-->
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79 | </select></td>
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80 | </tr>
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81 | <tr><td height="7"></td>
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82 | </tr>
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83 | <tr>
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84 | <td><input type="text" name="addr01" value="<!--{$arrForm.addr01}-->" size="60" class="box60" style="<!--{$arrErr.addr01|sfGetErrorColor}-->; ime-mode: active;" /></td>
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85 | </tr>
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86 | <tr>
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87 | <td class="fs10n"><!--{$smarty.const.SAMPLE_ADDRESS1}--></td>
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88 | </tr>
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89 | <tr><td height="5"></td></tr>
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90 | <tr>
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91 | <td><input type="text" name="addr02" value="<!--{$arrForm.addr02}-->" size="60" class="box60" style="<!--{$arrErr.addr02|sfGetErrorColor}-->; ime-mode: active;" /></td>
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92 | </tr>
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93 | <tr>
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94 | <td class="fs10n"><!--{$smarty.const.SAMPLE_ADDRESS2}--></td>
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95 | </tr>
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96 | <tr><td height="5"></td></tr>
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97 | <tr>
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98 | <td class="fs10"><span class="red">½»½ê¤Ï2¤Ä¤Ëʬ¤±¤Æ¤´µÆþ¤¤¤¿¤À¤±¤Þ¤¹¡£¥Þ¥ó¥·¥ç¥ó̾¤Ïɬ¤ºµÆþ¤·¤Æ¤¯¤À¤µ¤¤¡£</span></td>
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99 | </tr>
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100 | </table>
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101 | </td>
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102 | </tr>
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103 | <tr>
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104 | <td bgcolor="#f0f0f0" class="fs12n">ÅÅÏÃÈÖ¹æ<span class="red">¢¨</span></td>
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105 | <td bgcolor="#ffffff" class="fs12n"><span class="red"><!--{$arrErr.tel01}--><!--{$arrErr.tel02}--><!--{$arrErr.tel03}--></span><input type="text" name="tel01" value="<!--{$arrForm.tel01}-->" maxlength="<!--{$smarty.const.TEL_ITEM_LEN}-->" size="6" style="<!--{$arrErr.tel01|sfGetErrorColor}-->; ime-mode: disabled;" /> - <input type="text" name="tel02" value="<!--{$arrForm.tel02}-->" maxlength="<!--{$smarty.const.TEL_ITEM_LEN}-->" size="6" style="<!--{$arrErr.tel02|sfGetErrorColor}-->; ime-mode: disabled;" /> - <input type="text" name="tel03" value="<!--{$arrForm.tel03}-->" maxlength="<!--{$smarty.const.TEL_ITEM_LEN}-->" size="6" style="<!--{$arrErr.tel03|sfGetErrorColor}-->; ime-mode: disabled;" /></td>
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106 | </td>
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107 | </tr>
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108 | <tr>
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109 | <td bgcolor="#f0f0f0" class="fs12n">FAX</td>
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110 | <td bgcolor="#ffffff" class="fs12n"><span class="red"><!--{$arrErr.fax01}--><!--{$arrErr.fax02}--><!--{$arrErr.fax03}--></span><input type="text" name="fax01" value="<!--{$arrForm.fax01}-->" maxlength="<!--{$smarty.const.TEL_ITEM_LEN}-->" size="6" style="<!--{$arrErr.fax01|sfGetErrorColor}-->; ime-mode: disabled;" /> - <input type="text" name="fax02" value="<!--{$arrForm.fax02}-->" maxlength="<!--{$smarty.const.TEL_ITEM_LEN}-->" size="6" style="<!--{$arrErr.fax02|sfGetErrorColor}-->; ime-mode: disabled;" /> - <input type="text" name="fax03" value="<!--{$arrForm.fax03}-->" maxlength="<!--{$smarty.const.TEL_ITEM_LEN}-->" size="6" style="<!--{$arrErr.fax03|sfGetErrorColor}-->; ime-mode: disabled;" /></td>
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111 | </tr>
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112 | <tr>
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113 | <td bgcolor="#f0f0f0" class="fs12n">¥á¡¼¥ë¥¢¥É¥ì¥¹<span class="red">¢¨</span></td>
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114 | <td bgcolor="#ffffff">
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115 | <table border="0" cellspacing="0" cellpadding="0" summary=" ">
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116 | <tr>
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117 | <td class="fs12n"><span class="red"><!--{$arrErr.email}--></span>
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118 | <input type="text" name="email" value= "<!--{$arrForm.email}-->" style="<!--{$arrErr.email|sfGetErrorColor}-->; ime-mode: disabled;" maxlength="<!--{$smarty.const.MTEXT_LEN}-->" size=40 class="box40" /></td>
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119 | </tr>
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120 | <tr><td height="5"></td></tr>
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121 | <tr>
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122 | <td class="fs12n"><span class="red"><!--{$arrErr.email02}--></span>
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123 | <input type="text" name="email02" value= "<!--{if $arrForm.email02 == ""}--><!--{$arrForm.email}--><!--{else}--><!--{$arrForm.email02}--><!--{/if}-->" style="<!--{$arrErr.email02|sfGetErrorColor}-->; ime-mode: disabled;" maxlength="<!--{$smarty.const.MTEXT_LEN}-->" size=40 class="box40" /></td>
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124 | </tr>
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125 | <tr><td height="2"></td></tr>
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126 | <tr>
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127 | <td class="fs10n"><span class="red">³Îǧ¤Î¤¿¤á2ÅÙÆþÎϤ·¤Æ¤¯¤À¤µ¤¤¡£</span></td>
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128 | </tr>
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129 | </table>
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130 | </td>
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131 | </tr>
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132 | <tr>
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133 | <td bgcolor="#f0f0f0" class="fs12n">ÀÊÌ<span class="red">¢¨</span></td>
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134 | <td bgcolor="#ffffff" class="fs12n">
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135 | <span class="red"><!--{$arrErr.sex}--></span><input type="radio" id="man" name="sex" value="1" style="<!--{$arrErr.sex|sfGetErrorColor}-->" <!--{if $arrForm.sex eq 1}--> checked <!--{/if}--> /><label for="man">ÃËÀ</label>¡¡<input type="radio" id="woman" name="sex" value="2" style="<!--{$arrErr.sex|sfGetErrorColor}-->" <!--{if $arrForm.sex eq 2}--> checked <!--{/if}--> /><label for="woman">½÷À</label></td>
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136 | </tr>
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137 | <tr>
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138 | <td bgcolor="#f0f0f0" class="fs12n">¿¦¶È</td>
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139 | <td bgcolor="#ffffff">
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140 | <span class="red"><!--{$arrErr.job}--></span>
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141 | <select name="job">
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142 | <option value="" selected>ÁªÂò¤·¤Æ¤¯¤À¤µ¤¤</option>
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143 | <!--{html_options options=$arrJob selected=$arrForm.job}-->
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144 | </select>
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145 | </td>
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146 | </tr>
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147 | <tr>
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148 | <td bgcolor="#f0f0f0" class="fs12n">À¸Ç¯·îÆü</td>
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149 | <td bgcolor="#ffffff" class="fs12n"><span class="red"><!--{$arrErr.year}--><!--{$arrErr.month}--><!--{$arrErr.day}--></span>
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150 | <select name="year" style="<!--{$arrErr.year|sfGetErrorColor}-->">
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151 | <option value="" selected>--</option>
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152 | <!--{html_options options=$arrYear selected=$arrForm.year}-->
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153 | </select> ǯ
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154 | <select name="month" style="<!--{$arrErr.month|sfGetErrorColor}-->"><span class="red"><!--{$arrErr.month}--></span>
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155 | <option value="" selected>--</option>
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156 | <!--{html_options options=$arrMonth selected=$arrForm.month}-->
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157 | </select> ·î
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158 | <select name="day" style="<!--{$arrErr.day|sfGetErrorColor}-->"><span class="red"><!--{$arrErr.day}--></span>
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159 | <option value="" selected>--</option>
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160 | <!--{html_options options=$arrDay selected=$arrForm.day}-->
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161 | </select> Æü
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162 | </td>
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163 | </tr>
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164 |
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165 | <tr>
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166 | <td bgcolor="#f0f0f0"><span class="fs12">´õ˾¤¹¤ë¥Ñ¥¹¥ï¡¼¥É<span class="red">¢¨</span></span><br>
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167 | <span class="fs10">¥Ñ¥¹¥ï¡¼¥É¤Ï¹ØÆþ»þ¤ËɬÍפǤ¹</span></td>
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168 | <td bgcolor="#ffffff">
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169 | <table cellspacing="0" cellpadding="0" summary=" ">
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170 | <tr>
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171 | <td class="fs12n"><span class="red"><!--{$arrErr.password}--></span>
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172 | <input type="password" name="password" value="<!--{$arrForm.password}-->" maxlength="<!--{$smarty.const.PASSWORD_LEN2}-->" style="<!--{$arrErr.password|sfGetErrorColor}-->" size=15 class="box15" /></td>
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173 | </tr>
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174 | <tr><td height="2"></td></tr>
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175 | <tr>
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176 | <td class="fs10n"><span class="red">Ⱦ³Ñ±Ñ¿ô»ú4¡Á10ʸ»ú¤Ç¤ª´ê¤¤¤·¤Þ¤¹¡£¡Êµ¹æÉԲġË</span></td>
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177 | </tr>
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178 | <tr><td height="5"></td></tr>
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179 | <tr>
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180 | <td class="fs12n"><span class="red"><!--{$arrErr.password02}--></span>
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181 | <input type="password" name="password02" value="<!--{$arrForm.password02}-->" maxlength="<!--{$smarty.const.PASSWORD_LEN2}-->" style="<!--{$arrErr.password02|sfGetErrorColor}-->" size=15 class="box15" /></td>
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182 | </tr>
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183 | <tr><td height="2"></td></tr>
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184 | <tr>
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185 | <td class="fs10n"><span class="red">³Îǧ¤Î¤¿¤á¤Ë2ÅÙÆþÎϤ·¤Æ¤¯¤À¤µ¤¤¡£</span></td>
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186 | </tr>
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187 | </table>
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188 | </td>
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189 | </tr>
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190 | <tr>
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191 | <td bgcolor="#f0f0f0" class="fs12">¥Ñ¥¹¥ï¡¼¥É¤ò˺¤ì¤¿»þ¤Î¥Ò¥ó¥È<span class="red">¢¨</span></td>
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192 | <td bgcolor="#ffffff">
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193 | <table cellspacing="0" cellpadding="0" summary=" ">
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194 | <tr>
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195 | <td class="fs12n"><span class="red"><!--{$arrErr.reminder}--></span><select name="reminder" style="<!--{$arrErr.reminder|sfGetErrorColor}-->">
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196 | <option value="" selected>ÁªÂò¤·¤Æ¤¯¤À¤µ¤¤</option>
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197 | <!--{html_options options=$arrReminder selected=$arrForm.reminder}-->
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198 | </select>
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199 | </td>
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200 | </tr>
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201 | <tr><td height="5"></td></tr>
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202 | <tr>
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203 | <td class="fs12n"><span class="red"><!--{$arrErr.reminder_answer}--></span><input type="text" name="reminder_answer" value="<!--{$arrForm.reminder_answer}-->" style="<!--{$arrErr.reminder_answer|sfGetErrorColor}-->; ime-mode: active;" size=40 class="box40" /></td>
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204 | </tr>
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205 | </table>
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206 | </td>
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207 | </tr>
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208 | <tr>
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209 | <td bgcolor="#f0f0f0" class="fs12">¥á¡¼¥ë¥Þ¥¬¥¸¥óÁ÷ÉդˤĤ¤¤Æ<span class="red">¢¨</span></td>
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210 | <td bgcolor="#ffffff" class="fs12">
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211 | <span class="red"><!--{$arrErr.mailmaga_flg}--></span>
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212 | <input type="radio" name="mailmaga_flg" value="1" id="html" style="<!--{$arrErr.mailmaga_flg|sfGetErrorColor}-->" <!--{if $arrForm.mailmaga_flg eq 1}--> checked <!--{/if}--> />HTML¥á¡¼¥ë¡Ü¥Æ¥¥¹¥È¥á¡¼¥ë¤ò¼õ¤±¼è¤ë</label><br>
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213 | <input type="radio" name="mailmaga_flg" value="2" id="text" style="<!--{$arrErr.mailmaga_flg|sfGetErrorColor}-->" <!--{if $arrForm.mailmaga_flg eq 2}--> checked <!--{/if}--> /><label for="text">¥Æ¥¥¹¥È¥á¡¼¥ë¤ò¼õ¤±¼è¤ë</label><br>
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214 | <input type="radio" name="mailmaga_flg" value="3" id="no" style="<!--{$arrErr.mailmaga_flg|sfGetErrorColor}-->" <!--{if $arrForm.mailmaga_flg eq 3}--> checked <!--{/if}--> /><label for="no">¼õ¤±¼è¤é¤Ê¤¤</label>
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215 | </td>
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216 | </tr>
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217 | </table>
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218 | <!--ÆþÎÏ¥Õ¥©¡¼¥à¤³¤³¤Þ¤Ç-->
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219 | </td>
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220 | </tr>
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221 | <tr><td height="20"></td></tr>
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222 | <tr>
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223 | <td align="center">
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224 | <input type="image" onmouseover="chgImgImageSubmit('<!--{$smarty.const.URL_DIR}-->img/common/b_confirm_on.gif',this)" onmouseout="chgImgImageSubmit('<!--{$smarty.const.URL_DIR}-->img/common/b_confirm.gif',this)" src="<!--{$smarty.const.URL_DIR}-->img/common/b_confirm.gif" width="150" height="30" alt="³Îǧ¥Ú¡¼¥¸¤Ø" name="refusal" id="refusal" />
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225 | </td>
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226 | </tr>
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227 | </form>
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228 | </table>
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229 | </td>
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230 | </tr>
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231 | </table>
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232 | <!--¢¥MAIN ONTENTS-->
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233 | </td>
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234 | </tr>
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235 | </table>
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236 | <!--¢¥CONTENTS-->
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237 |
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