I have a form here, which one copy of what was filled out in the form gets sent to the person who filled it out, and one to the company, but I also need to someone give them a unique confirmation number with the email.
Anyone can point me in the right direction?
Code: Select all
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<title>Cat & Dog Tag Renewal Form</title>
<script language="javascript" type="text/javascript">
//<![CDATA[
var tl_loc0=(window.location.protocol == "https:")? "https://secure.comodo.net/trustlogo/javascript/trustlogo.js" :
"http://www.trustlogo.com/trustlogo/javascript/trustlogo.js";
document.writeln('<scr' + 'ipt language="JavaScript" src="'+tl_loc0+'" type="text\/javascript">' + '<\/scr' + 'ipt>');
//]]>
</script>
</head>
<body topmargin ="0" leftmargin="0" marginwidth="0" marginheight="0" onLoad="createExpiry();">
<p><img border="0" src="../../My Documents/web sites/accpets/images/header.jpg" width="675" height="119"></p>
<table border="0" width="800" cellspacing="0" cellpadding="0">
<tr>
<td width="3%"></td>
<td width="97%">
<form method="POST" action="msg_conf.php">
<table border="0" width="483" height="48" cellspacing="0" cellpadding="0">
<tr>
<td width="114" height="19" valign="middle">Please Enter ID #:</td>
<td width="160" height="19" align="center" valign="middle">
<input type="text" name="ID_Number" size="22" tabindex="1" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
<td width="203" height="19" align="center">
(found above surname on your invoice)</td>
</tr>
<tr>
<td width="114" height="19"></td>
<td width="160" height="19" align="center"></td>
<td width="203" height="19" align="center"></td>
</tr>
<tr>
<td width="114" height="19" valign="bottom">Name:</td>
<td width="160" height="19" align="center">
<input type="text" name="Surname" size="22" tabindex="2" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
<td width="203" height="19" align="center" valign="bottom">
<input type="text" name="Given_Name" size="25" tabindex="3" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="114" height="17"></td>
<td width="160" height="17" align="center">(Surname)</td>
<td width="203" height="17" align="center">(Given)</td>
</tr>
<tr>
<td width="114" height="17">E-Mail Address:</td>
<td width="363" height="17" align="center" colspan="2">
<p align="left">
<input type="text" name="Email_Address" size="42" tabindex="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr height=5>
<td align="center" colspan="3">
</td>
</tr>
<tr>
<td align=center colspan=3>
<font size=2>*a confirmation number will be emailed to the above addess upon submission</font>
</td>
</tr>
<tr height=15>
<td align="center" colspan="3">
</td>
</tr>
</table>
<table width="485" height="50" cellspacing="0" cellpadding="2" style="border-width:1px;border-color:#ff0000;border-style:solid">
<tr>
<td colspan="2" width="485" height="19">Have you had a change in address or phone number over the last year?</td>
</tr>
<tr>
<td><input type="radio" value="change_yes" name="Contact_Change" tabindex="5">Yes</td>
</tr>
<tr>
<td><input type="radio" value="change_no" name="Contact_Change" tabindex="6">No</td>
</tr>
</table>
<br/>
<table border="0" width="485" height="100" cellspacing="0" cellpadding="0">
<tr>
<td width="305" height="19">Address:</td>
<td width="390" height="19" align="left">
<input type="text" name="Address" size="51" tabindex="7" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="305" height="17"></td>
<td width="390" height="17" align="left">Apt#
Street# Street</td>
</tr>
<tr>
<td width="305" height="15"></td>
<td width="390" height="15" align="center"></td>
</tr>
<tr>
<td width="305" height="17">Municipality:</td>
<td width="390" height="17" align="left">
<input type="text" name="Municipality" size="22" value="London" tabindex="8" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="305" height="17">Province:</td>
<td width="390" height="17" align="left">
<input type="text" name="Province" size="22" tabindex="9" value="ON" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="305" height="17">Postal Code:</td>
<td width="390" height="17" align="left">
<input type="text" name="Postal_Code" size="22" tabindex="10" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="305" height="17"></td>
<td width="390" height="17" align="left"></td>
</tr>
<tr>
<td width="305" height="17" rowspan="2">Phone #<br/>(with area code):</td>
<td width="390" height="17" align="left">Home:
<input type="text" name="Phone_Home" size="12" tabindex="11" maxlength="12" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"> (eg. 519-555-5555)</td>
</tr>
<tr>
<td width="390" height="17" align="left">Work:
<input type="text" name="Phone_Work" size="12" tabindex="12" maxlength="12" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
ext: <input type="text" name="Phone_Work_Extension" size="8" tabindex="13" maxlength="8" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
</table>
<p>
</p>
<table border="0" width="538" cellspacing="0" cellpadding="0">
<tr>
<td width="130"><b>Billing Information</b></td>
<td width="234"></td>
</tr>
<tr>
<td width="130" rowspan="2">
<!-- Authentic Trust Logo Seal verification code START -->
<!--
TrustLogo Html Builder Code:
Shows the logo at URL http://www.accpets.ca/images/trust_logo.GIF
Logo type is ("SC4")
Not Floating
//-->
<a href="http://www.instantssl.com" id="comodoTL">SSL</a>
<script type="text/javascript">TrustLogo("http://www.accpets.ca/images/trust_logo.GIF", "SC4", "none");</script>
<!-- Authentic Trust Logo Seal verification code END -->
</td>
<td width="234"><input type="radio" value="MasterCard" name="Card_Type" tabindex="14" checked>MasterCard</td>
</tr>
<tr>
<td width="234"><input type="radio" value="Visa" name="Card_Type" tabindex="15">Visa</td>
</tr>
<tr>
<td width="130"></td>
<td width="234"></td>
</tr>
<tr>
<td width="130">Name of Cardholder:</td>
<td width="234"><input type="text" name="CreditCardName" size="45" tabindex="16" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="130">Card #: </td>
<td width="300">
<input type="text" name="CardNumber" size="4" tabindex="17" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<input type="text" name="CardNumber1" size="4" tabindex="18" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<input type="text" name="CardNumber2" size="4" tabindex="19" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<input type="text" name="CardNumber3" size="4" tabindex="20" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="130">Expiry Date: </td>
<td width="234">
<select size="1" name="Expiry_Month" tabindex="21" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>MM</option>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select>
<select size="1" name="Expiry_Year" tabindex="22" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>YYYY</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
</select></td>
</tr>
</table>
<p>Please indicate amount to be paid: $ <input type="text" name="Amount_Paid" size="13" tabindex="23" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></p>
<p> </p>
<table border="0" width="539" cellspacing="0" cellpadding="0" height="69">
<tr>
<td width="262" height="21"><b>Rabies Information</b></td>
<td width="261" height="21"></td>
</tr>
<tr>
<td width="262" height="25">Veterinarian Clinic Name</td>
<td width="261" height="25" valign="middle">
<input type="text" name="vet_clinic_name" size="20" tabindex="24" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<br>
<br>
</td>
</tr>
<tr>
<td width="262" height="23">Name of First Animal</td>
<td width="261" height="23">
<input type="text" name="Animal1_Name" size="20" tabindex="25" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="262" height="23">Month and Year of Vaccination</td>
<td width="261" height="23">
<select size="1" name="Rabies_Month_Animal1" tabindex="26" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>MM</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select>
<select size="1" name="Rabies_Year_Animal1" tabindex="27" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>YYYY</option>
<option>2002</option>
<option>2003</option>
<option>2004</option>
<option>2005</option>
<option>2006</option>
<option>2007</option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
</select>
<br>
<br>
</td>
</tr>
<tr>
<td width="262" height="23">Name of Second Animal</td>
<td width="261" height="23">
<input type="text" name="Animal2_Name" size="20" tabindex="28" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="262" height="23">Month and Year of Vaccination</td>
<td width="261" height="23">
<select size="1" name="Rabies_Month_Animal2" tabindex="29" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>MM</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select>
<select size="1" name="Rabies_Year_Animal2" tabindex="30" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>YYYY</option>
<option>2002</option>
<option>2003</option>
<option>2004</option>
<option>2005</option>
<option>2006</option>
<option>2007</option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
</select>
<br>
<br>
</td>
</tr>
<tr>
<td width="262" height="23">Name of Third Animal</td>
<td width="261" height="23">
<input type="text" name="Animal3_Name" size="20" tabindex="31" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
</tr>
<tr>
<td width="262" height="23">Month and Year of Vaccination</td>
<td width="261" height="23">
<select size="1" name="Rabies_Month_Animal3" tabindex="32" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>MM</option>
<option value="January">January</option>
<option value="February">February</option>
<option value="March">March</option>
<option value="April">April</option>
<option value="May">May</option>
<option value="June">June</option>
<option value="July">July</option>
<option value="August">August</option>
<option value="September">September</option>
<option value="October">October</option>
<option value="November">November</option>
<option value="December">December</option>
</select>
<select size="1" name="Rabies_Year_Animal3" tabindex="33" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
<option>YYYY</option>
<option>2002</option>
<option>2003</option>
<option>2004</option>
<option>2005</option>
<option>2006</option>
<option>2007</option>
<option>2008</option>
<option>2009</option>
<option>2010</option>
<option>2011</option>
</select></td>
</tr>
</table>
<table>
<tr height="15">
<td></td>
</tr>
</table>
<table border="0" cellpadding="0" cellspacing="0" width="600">
<tr>
<td><strong>Breed Certification</strong><br /><i>(if only renewing cat identification tags, please select the
Cat renewal only box)</i>
</td>
</tr>
<tr height="10">
<td>
</td>
</tr>
<tr>
<td><input type="radio" name="DogOrCat" value="No Pit Bull - Declared" />I am the Owner of the
above indicated dog(s) and the dog(s) is/are not Pit Bull dog(s)<br /> as defined in the
City of London's Pit Bull dog licensing by-law.
</td>
</tr>
<tr>
<td><input type="radio" name="DogOrCat" value="Cat renewal only" />Cat renewal only</td>
</tr>
</table>
<p> </p>
<p>Notes: If amount to be paid does not match amount invoiced, please explain
in the box provided.<b>*</b></p>
<p> <textarea rows="4" name="Notes" cols="72" tabindex="34" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></textarea></p>
<p><b>*If spay/neuter has occurred in past year, please provide veterinary
name and phone number for follow up.</b></p>
<p align="center">
<input type="submit" value="Submit" name="B1">
<input type="reset" value="Reset" name="B2">
</p>
</form>
</table>
<?php
} else {
error_reporting(0);
$recipient = 'contact@justspiffy.ca';
$ID_Number = stripslashes($_POST['ID_Number']);
$Surname = stripslashes($_POST['Surname']);
$Given_name = stripslashes($_POST['Given_name']);
$Email_Address = stripslashes($_POST['Email_Address']);
$Contact_Change = stripslashes($_POST['Contact_Change']);
$Address = stripslashes($_POST['Address']);
$Municipality = stripslashes($_POST['Municipality']);
$Province = stripslashes($_POST['Province']);
$Postal_Code = stripslashes($_POST['Postal_Code']);
$Phone_Home = stripslashes($_POST['Phone_Home']);
$Phone_Work = stripslashes($_POST['Phone_Work']);
$Phone_Work_Extension = stripslashes($_POST['Phone_Work_Extension']);
$Card_Type = stripslashes($_POST['Card_Type']);
$CreditCardName = stripslashes($_POST['CreditCardName']);
$CardNumber = stripslashes($_POST['CardNumber']);
$CardNumber1 = stripslashes($_POST['CardNumber1']);
$CardNumber2 = stripslashes($_POST['CardNumber2']);
$CardNumber3 = stripslashes($_POST['CardNumber3']);
$Expiry_Month = stripslashes($_POST['Expiry_Month']);
$Expiry_Year = stripslashes($_POST['Expiry_Year']);
$Amount_Paid = stripslashes($_POST['Amount_Paid']);
$vet_clinic_name = stripslashes($_POST['vet_clinic_name']);
$Animal1_Name = stripslashes($_POST['Animal1_Name']);
$Rabies_Month_Animal1 = stripslashes($_POST['Rabies_Month_Animal1']);
$Rabies_Year_Animal1 = stripslashes($_POST['Rabies_Year_Animal1']);
$Animal2_Name = stripslashes($_POST['Animal2_Name']);
$Rabies_Month_Animal2 = stripslashes($_POST['Rabies_Month_Animal2']);
$Rabies_Year_Animal2 = stripslashes($_POST['Rabies_Year_Animal2']);
$Animal3_Name = stripslashes($_POST['Animal3_Name']);
$Rabies_Month_Animal3 = stripslashes($_POST['Rabies_Month_Animal3']);
$Rabies_Year_Animal3 = stripslashes($_POST['Rabies_Year_Animal3']);
$DogOrCat = stripslashes($_POST['DogOrCat']);
$Notes = stripslashes($_POST['Notes']);
$sendto = $_POST['Email_Address'];
$headers = "From: $recipient\r\n\r\n";
$subject = "Dog & Cat Tag Renewal";
$message = "Thank you for registering your pet with London Animal Care Centre.\n
Please keep this email as proof of your application for your
dog licence or cat identification tag.<br />
Your confirmation Id is \n
If you have any questions or concerns please call (519)685-1330
and have your confirmation id available.\n
Please allow 3 to 6 weeks for processing and delivery of your tags.\n
ID #: $ID_Number\r\n
Name: $Surname $Given_name\r\n
E-Mail Address: $Email_Address\r\n
Have you had a change in address or phone number over the last year?: $Contact_Change\r\n
Address: $Address\r\n
Municipality: $Municipality\r\n
Province: $Province\r\n
Postal Code: $Postal_Code\r\n
Phone # - Home: $Phone_Home\r\n
Phone # - Work: $Phone_Work\r\n
Work Ext: $Phone_Work_Extension\r\n
Card Type: $Card_Type\r\n
Name of Cardholder: $CreditCardName\r\n
Card #: XXXX-XXXX-XXXX-$CardNumber3\r\n
Expiry Date: $Expiry_Month $Expiry_Year\r\n
Please indicate amount to be paid: $Amount_Paid\r\n
Veterinarian Clinic Name: $vet_clinic_name\r\n
Name of First Animal: $Animal1_Name\r\n
Month and Year of Vaccination: $Rabies_Month_Animal1 $Rabies_Year_Animal1\r\n
Name of Second Animal: $Animal2_Name\r\n
Month and Year of Vaccination: $Rabies_Month_Animal2 $Rabies_Year_Animal2\r\n
Name of Third Animal: $Animal3_Name\r\n
Month and Year of Vaccination: $Rabies_Month_Animal3 $Rabies_Year_Animal3\r\n
Breed Certification: $DogOrCat\r\n
Notes: $Notes\r\n
";
// Send mail to customer, refer to http://php.net/manual/en/function.mail.php
mail($sendto, $subject, $message, $headers);
if (!mail) {
echo "Message failed to send, please notify our Web Team.";
} else {
echo nl2br ("<center><br><br><br><br><br><br><br><br><br><br>Thank you. Your request has been sent and we will contact you shortly.<br><br><br><br><br><br><br><br><br><br></center>");
}
// Send mail to company
$to = "contact@justspiffy.ca"; // who gets this one?
$message = "Thank you for registering your pet with London Animal Care Centre.\n
Please keep this email as proof of your application for your
dog licence or cat identification tag.<br />
Your confirmation Id is \n
If you have any questions or concerns please call (519)685-1330
and have your confirmation id available.\n
Please allow 3 to 6 weeks for processing and delivery of your tags.\n
ID #: $ID_Number\r\n
Name: $Surname $Given_name\r\n
E-Mail Address: $Email_Address\r\n
Have you had a change in address or phone number over the last year?: $Contact_Change\r\n
Address: $Address\r\n
Municipality: $Municipality\r\n
Province: $Province\r\n
Postal Code: $Postal_Code\r\n
Phone # - Home: $Phone_Home\r\n
Phone # - Work: $Phone_Work\r\n
Work Ext: $Phone_Work_Extension\r\n
Card Type: $Card_Type\r\n
Name of Cardholder: $CreditCardName\r\n
Card #: $CardNumber $CardNumber1 $CardNumber2 $CardNumber3\r\n
Expiry Date: $Expiry_Month $Expiry_Year\r\n
Please indicate amount to be paid: $Amount_Paid\r\n
Veterinarian Clinic Name: $vet_clinic_name\r\n
Name of First Animal: $Animal1_Name\r\n
Month and Year of Vaccination: $Rabies_Month_Animal1 $Rabies_Year_Animal1\r\n
Name of Second Animal: $Animal2_Name\r\n
Month and Year of Vaccination: $Rabies_Month_Animal2 $Rabies_Year_Animal2\r\n
Name of Third Animal: $Animal3_Name\r\n
Month and Year of Vaccination: $Rabies_Month_Animal3 $Rabies_Year_Animal3\r\n
Breed Certification: $DogOrCat\r\n
Notes: $Notes\r\n
";
mail($to, $subject, $message, $headers);
if (!mail) {
echo "Message failed to send. Please notify our Web Team.";
} else {
// something here to notify the web team if it fails.
}
}
?>
<p>
<!-- Seal verification code START --> <!-- Seal verification code END --></p>
</body>
</html>
[\code]