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 <title>Deschide un cont completand formularul de mai jos:</title>
<div class="bold size14">Deschide un cont completand formularul de mai jos:</div>

	  
<form name="signup" method="post" action="">
		

  
   
  <p>RoConnect.com mentine o politica de stricta confidentialitate a datelor personale 
    asa cum este specificat in <a href="http://www.roconnect.com/privacy_e.php" class="cl4" target="_blank"><font color="#FF641A">Nota 
    de Confidentialitate</font></a>. Deasemenea, transmiterea datelor personale 
    se face utilizand o conexiune securizata SSL pe 128 biti.<br />
      </p>
  <p>*Prenume:<br>
    <input type="text" size="30" name="name" value="">
    (cum apare pe cartea de credit) <br>
    *Nume:<br>
    <input type="text" size="30" name="surname" value="">
    (cum apare pe cartea de credit) <br>
    *E-mail:<br>
    <input type="text" size="30" name="email" value="">
    (adresa folosita pentru logare,suport, facturare) <br>
    *Confirma adresa de email:<br>
    <input type="text" size="30" name="reemail" value="">
    (adresa folosita pentru logare,suport, facturare) <br>
    *Parola:<br>
    <input type="password" size="30" name="parola" value="">
    (parola folosita pentru logare) <br>
    *Confirma parola:<br>
    <input type="password" size="30" name="reeparola" value="">
    (parola folosita pentru logare) <br>
    *Adresa:<br>
    <input type="text" size="30" name="address" value="">
    <br>
    *Oras:<br>
    <input type="text" size="30" name="city" value="">
    <br>
    *Cod postal:<br>
    <input type="text" size="30" name="postal_code" value="">
    <br>
    *Stat/provincie:<br>
    <input type="text" size="30" name="state" value="">
    <br>
    *Tara de domiciliu:<br>
    <input type="text" size="30" name="country" value="">
    <br>
    *Telefon:<br>
    <input type="text" size="30" name="tel" value="">
    <br>
    Telefon 2:<br>
    <input type="text" size="30" name="tel2" value="">
    <br>
    Telefon 3:<br>
    <input type="text" size="30" name="tel3" value="">
    <br>
    Referinta:<br>
    <input type="text" size="30" name="ref" value="">
    (daca ati aflat despre serviciile noastre de la un alt abonat <b>RoConnect</b>, 
    introduceti aici numele) <br>
    <br>
    <input type="submit" value="Continua" class="loginbtn">
    <br>
  </p>
    
  <p align="center"><img src="https://www.roconnect.com/images/horz_master_85pixels.gif" alt="Trusted site"></p>
</form>

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