Here is my Form code:
Code: Select all
<h1><a>Residential Application</a></h1>
<form method="post" action="contact.php">
<div class="form_description">
<h2>Residential Application</h2>
<p>Dear Earlville Buying Group Member,</p>
<p> Ferrellgas is proud to be the propane supplier for the Earlville Buying Group. In order to process your application, please return the enclosed application applicable annual membership fee, to Ralph Griffiths via mail to:</p>
<p><strong>Earlville Buyers Group<br>
PO Box 200<br>
Sherburne, NY, 13460<br>
</strong> </p>
<p> A commercial application must also be completed for businesses.Thank you for your time.</p>
<p><strong>Ralph Griffiths<br>
Phone 1-607-316-6008<br>
Fax: 1-607-330-3664</strong></p>
</div>
<ul >
<li id="li_1" ><strong>Full Name</strong>
<div>
<input id="Full_Name_1" name="Full_Name" class="element text" type="text" maxlength="255" value=""/>
</div>
</li> <li id="li_2" >
<label class="description" for="element_2">Phone </label>
<span>
<input id="Phone_1" name="Phone" class="element text" size="18" maxlength="13" value="" type="text"><br />
###-###-####</span></li> <li id="li_3" >
<label class="description" for="element_3">Billing Address </label>
<div>
<input id="Billing_Address_1" name="Billing_Address" class="element text large" value="" type="text">
<label for="element_3_1">Street Address or PO Box</label>
</div>
<div>
<input id="Billing_address_line_2" name="Billing_address_line_2" class="element text large" value="" type="text">
<label for="element_3_2">Address Line 2</label>
</div>
<div class="left">
<input id="City" name="City" class="element text medium" value="" type="text">
<label for="element_3_3">City</label>
</div>
<div class="right">
<input id="State" name="State" class="element text medium" value="" type="text">
<label for="element_3_4">State / Province / Region</label>
</div>
<div class="left">
<input id="Zip" name="Zip_Code" class="element text medium" maxlength="15" value="" type="text">
<label for="element_3_5">Postal / Zip Code</label>
</div>
</li> <li id="li_4" >
<label class="description" for="element_4">Delivery Address (If Different from Billing) </label>
<div>
<input id="Delivery_Address" name="Delivery_Address_Line_1" class="element text large" value="" type="text">
<label for="element_4_1">Street Address</label>
</div>
<div>
<input id="Delivery_Address_line_2" name="Delivery_Address_line_2" class="element text large" value="" type="text">
<label for="element_4_2">Address Line 2</label>
</div>
<div class="left">
<input id="Delivery_City" name="Delivery_City" class="element text medium" value="" type="text">
<label for="element_4_3">City</label>
</div>
<div class="right">
<input id="Delivery_State" name="Delivery_State" class="element text medium" value="" type="text">
<label for="element_4_4">State / Province / Region</label>
</div>
<div class="left">
<input id="Delivery_Zip_Code" name="Delivery_Zip_Code" class="element text medium" maxlength="15" value="" type="text">
<label for="element_4_5">Postal / Zip Code</label>
</div>
<div class="right"></div>
</li> <li id="li_5" >
<label class="description" for="element_5">Email </label>
<div>
<input id="Email" name="Email" class="element text medium" type="text" maxlength="255" value=""/>
</div>
</li> <li id="li_6" >
<label class="description" for="element_6">Current Tank Size </label>
<div>
<input id="Current_Tank_Size" name="Current_Tank_Size" class="element text medium" type="text" maxlength="255" value=""/>
</div>
</li> <li id="li_15" >
<label class="description" for="element_15">Tank Location </label>
<span>
<input id="Tank_Location_Above" name="Tank_Location_Above" class="element radio" type="radio" value="Above Ground" />
<label class="choice" for="element_15_1">Above Ground</label>
<input id="Tank_Location_Below" name="Tank_Location_Below" class="element radio" type="radio" value="Below Ground" />
<label class="choice" for="element_15_2">Below Ground</label>
</span>
</li> <li id="li_16" >
<label class="description" for="element_16">Do you preffer automatic or will call delivery? </label>
<span>
<input id="element_16_1" name="Delivery_Preferance_1" class="element radio" type="radio" value="Will Call" />
<label class="choice" for="element_16_1">Will Call</label>
<input id="element_16_2" name="Delivery_preferance_2" class="element radio" type="radio" value="Automatic" />
<label class="choice" for="element_16_2">Automatic</label>
</span>
</li> <li id="li_7" >
<label class="description" for="element_7">If Automatic please tell us how often you would like delivery. </label>
<div>
<input id="element_7" name="how_often_you_would_like_delivery" class="element text large" type="text" maxlength="255" value=""/>
</div>
</li> <li id="li_8" >
<label class="description" for="element_8">Social Security Number </label>
<div>
<input id="element_8" name="Social_Security_Number" class="element text medium" type="text" maxlength="11" value=""/>
</div><p class="guidelines" id="guide_8"><small>123-12-1234</small></p>
</li> <li id="li_9" >
<label class="description" for="element_9">Date of Birth </label>
<span>
<input id="element_9_1" name="DOB" class="element text" size="15" maxlength="10" value="" type="text">
<label for="element_9_1">MM-DD-YYYY</label>
</span>
</li> <li id="li_10" >
<label class="description" for="element_10">Drivers License </label>
<div>
<input id="element_10" name="Drivers_License" class="element text medium" type="text" maxlength="255" value=""/>
</div>
</li> <li id="li_11" >
<label class="description" for="Employer_L">Employers Name and Address </label>
<div>
<textarea id="element_11" name="Employer_info" class="element textarea small"></textarea>
</div>
</li> <li id="li_12" >
<label class="description" for="element_12">Mothers Maiden Name </label>
<div>
<input id="element_12" name="Mothers_Maiden_Name" class="element text medium" type="text" maxlength="255" value=""/>
</div>
</li> <li id="li_13" >
<label class="description" for="element_13">Banks Name, Address and Phone # </label>
<div>
<textarea id="element_13" name="Bank_Info" class="element textarea small"></textarea>
</div>
</li> <li id="li_17" >
<label class="description" for="element_17">Do you already OWN your tanks? </label>
<span>
<input id="element_17_1" name="Do_You_Own_Your_Tanks_1" class="element radio" type="radio" value="Yes" />
<label class="choice" for="element_17_1">Yes</label>
<input id="element_17_2" name="Do_You_Own_Your_Tanks_2" class="element radio" type="radio" value="No" />
<label class="choice" for="element_17_2">No</label>
</span>
</li> <li id="li_14" >
<label class="description" for="element_14">What date would you like to start Delivery? </label>
<span>
<input id="element_14_1" name="Delivery_Start_Date" class="element text" size="15" maxlength="10" value="" type="text">
<label for="element_14_1">MM-DD-YYYY</label>
</span>
</li>
<li class="buttons">
<input type="hidden" name="form_id" value="303866" />
<input id="saveForm" class="button_text" type="submit" name="submit" value="Submit" />
</li>
</ul>
</form>Code: Select all
<?php
$Full_Name = $_REQUEST['Full_Name'] ;
$Phone = $_REQUEST['Phone'] ;
$Billing_Address = $_REQUEST['Billing_Address'] ;
$Billing_address_line_2 = $_REQUEST['Billing_address_line_2'] ;
$City = $_REQUEST['City'] ;
$State = $_REQUEST['State'] ;
$Zip_Code = $_REQUEST['Zip_Code'] ;
$Delivery_Address_Line_1 = $_REQUEST['Delivery_Address_Line_1'] ;
$Delivery_Address_Line_2 = $_REQUEST['Delivery_Address_Line_1'] ;
$Delivery_State = $_REQUEST['Delivery_State'] ;
$Delivery_Zip_Code = $_REQUEST['Delivery_Zip_Code'] ;
$Email = $_REQUEST['Email'] ;
$Current_Tank_Size = $_REQUEST['Current_Tank_Size'] ;
$Tank_Location_Above = $_REQUEST['Tank_Location_Above'] ;
$Tank_Location_Below = $_REQUEST['Tank_Location_Below'] ;
$Delivery_Preferance_1 = $_REQUEST['Delivery_Preferance_1'] ;
$Delivery_Preferance_2 = $_REQUEST['Delivery_Preferance_2'] ;
$how_often_you_would_like_delivery = $_REQUEST['how_often_you_would_like_delivery'] ;
$Social_Security_Number = $_REQUEST['Social_Security_Number'] ;
$DOB = $_REQUEST['DOB'] ;
$Drivers_License = $_REQUEST['Drivers_License'] ;
$Employer_info = $_REQUEST['Employer_info'] ;
$Mothers_Maiden_Name = $_REQUEST['Mothers_Maiden_Name'] ;
$Bank_Info = $_REQUEST['Bank_Info'] ;
$Do_You_Own_Your_Tanks_1 = $_REQUEST['Do_You_Own_Your_Tanks_1'] ;
$Do_You_Own_Your_Tanks_2 = $_REQUEST['Do_You_Own_Your_Tanks_2'] ;
$Delivery_Start_Date = $_REQUEST['Delivery_Start_Date'] ;
$message = $_REQUEST[''] ;
mail( "sales@earlvillebuyersgroup.com", "Residencial Application Submision",
$message, "From: $Email" );
header( "Location: http://www.earlvillebuyersgroup.net/Thank_You_For_your_Application.html" );
?>
I have searched all over and cant find anything i'm looking for. how i want it to look does not seem hard. eventually i would like it in HTML format but lets get the basics down first.
this is what i want it to look like in an email message
Full name: Customers full name from posted data
Phone #: Customers phone#
ETC
can any one help me format the $message variable to do this? even a video tutorial or sample.
Thanks WAY in advance.
HCS Droid