<?php
 
if(isset($_POST["Submit"]))
{
require("c:\php\includes\class.phpmailer.php");
 
$mail = new PHPMailer();
 
$toaddress = "rocky@airedale911.org";  //Change this to the email address you will be receiving your notices.
$mailhost = "mail.airedale911.org";  //Change this to your actual Domain name.
$fromaddress = "rocky@airedale911.org";  //Change this to the email address you will use to send and authenticate with.
$frompwd = "none";  //Change this to the above email addresses password.
$subject = "Airedale 911 Application Form";  //Change this to your own email message subject.
 
 
$referredby = $_POST["Referredby"];
$fromname = $_POST["Name"];
$street = $_POST["Street"] ;
$city = $_POST["City"];
$state = $_POST["State"];
$zip = $_POST["Zip"];
$homephone = $_POST["Homephone"] ;
$workphone = $_POST["Workphone"];
$cellphone = $_POST["Cellphone"];
$rplyto = $_POST["Email"];
$family = $_POST["Family"] ;
$sex = $_POST["Sex"] ;
$previouslyowned = $_POST["Previouslyowned"] ;
$whenpreviouslyowned = $_POST["Whenpreviouslyowned"] ;
$sexpreviouslyowned = $_POST["Sexpreviouslyowned"] ;
$otherbreeds = $_POST["Otherbreeds"] ;
$fateoflastdog = $_POST["Fateoflastdog"] ;
$lostadog = $_POST["Lostadog"] ;
$movegiveupdog = $_POST["Movegiveupdog"] ;
$otherpets = $_POST["Otherpets"] ;
$otherpetsages = $_POST["Otherpetsages"] ;
$otherpetsspayedneutered = $_POST["Otherpetsspayedneutered"] ;
$a = $_POST["A"] ;
$fencedinyard = $_POST["Fencedinyard"] ;
$kindoffence = $_POST["Kindoffence"] ;
$howhighfence = $_POST["Howhighfence"] ;
$sizeoffencedinarea = $_POST["Sizeoffencedinarea"] ;
$runofhouse = $_POST["Runofhouse"] ;
$allowedonfurniture = $_POST["Allowedonfurniture"] ;
$havebedandblanket = $_POST["Havebedandblanket"] ;
$dogbedinwhatroom = $_POST["Dogbedinwhatroom"] ;
$wherewillairedalesleep = $_POST["Wherewillairedalesleep"] ;
$hoursnoonehome = $_POST["Hoursnoonehome"] ;
$daysaweekalone = $_POST["Daysaweekalone"] ;
$whatroomabovetimes = $_POST["Whatroomabovetimes"] ;
$travelingwherewilldogstay = $_POST["Travelingwherewilldogstay"] ;
$familiardogcrate = $_POST["Familiardogcrate"] ;
$whenwheredogcrate = $_POST["Whenwheredogcrate"] ;
$reference1 = $_POST["Reference1"] ;
$reference2 = $_POST["Reference2"] ;
$vetinfo = $_POST["Vetinfo"] ;
$comments = $_POST["Comments"] ;
 
 
 
 
 
 
 
$msgbody = "Referred by  = " . $referredby
."<br>"
."Your Full Name  = " . $fromname
."<br>"
."Your Street Address  = " . $street
."<br>"
."City  = " . $city
."<br>"
."State  = " . $state
."<br>"
."Zip Code  = " . $zip
."<br>"
."Your home telephone number (xxx-xxx-xxxx)  = " . $homephone
."<br>"
."Your work number  = " . $workphone
."<br>"
."Your cell phone number  = " . $cellphone
."<br>"
."Email  = " . $rplyto
."<br>"
."lease list names and ages of all family members (including yourself), live-in help, frequent visitors, etc.  = " . $family
."<br>"
."Do you prefer a male or female Airedale?  = " . $sex
."<br>"
."Have you previously owned an Airedale?  = " . $previouslyowned
."<br>"
."When?  = " . $whenpreviouslyowned
."<br>"
."Male or Female?  = " . $sexpreviouslyowned
."<br>"
."What other dog breeds have you owned?  = " . $otherbreeds
."<br>"
."What happened to your last dog?  = " . $fateoflastdog
."<br>"
."Have you ever lost a dog other than through death? = " . $lostadog
."<br>"
."If you had to move, would you consider giving up your dog?  = " . $movegiveupdog
."<br>"
."What other pets do you currently have?  = " . $otherpets
."<br>"
."Their ages  = " . $otherpetsages
."<br>"
."Are they spayed/neutered?  = " . $otherpetsspayedneutered
."<br>"
."Are they currently licensed?  = " . $a
."<br>"
."Do you a fenced-in yard?  = " . $fencedinyard
."<br>"
."What kind of fence?  = " . $kindoffence
."<br>"
."How high is the fence?  = " . $howhighfence
."<br>"
."Size of fenced-in area?  = " . $sizeoffencedinarea
."<br>"
."Will your new Airedale have run of the house?  = " . $runofhouse
."<br>"
."Be allowed on the furniture?  = " . $allowedonfurniture
."<br>"
."Have his/her own dog bed and blankets?  = " . $havebedandblanket
."<br>"
."In what room will the dog bed be placed?  = " . $dogbedinwhatroom
."<br>"
."In what room will your new Airedale sleep?  = " . $wherewillairedalesleep
."<br>"
."How many hours at a time is no one at home?  = " . $hoursnoonehome
."<br>"
."How many days a week will your dog be left alone?  = " . $daysaweekalone
."<br>"
."In what room(s) will your dog be during the above times?  = " . $whatroomabovetimes
."<br>"
."When you travel, where will your dog stay?  = " . $travelingwherewilldogstay
."<br>"
."Are you familiar with a dog crate?  = " . $familiardogcrate
."<br>"
."When and where do you use one?  = " . $whenwheredogcrate
."<br>"
."Name, address, phone number  = " . $reference1
."<br>"
."Name, address, phone number  = " . $reference2
."<br>"
."Your veterinarian's name, address, phone number  = " . $vetinfo
."<br>"
."Comments  = " . $comments; 
 
 
 
$mail->IsSMTP();
$mail->Host = $mailhost;
$mail->SMTPAuth = true;
$mail->Username = $fromaddress;
$mail->Password = $frompwd;
 
$mail->From = $fromaddress;
$mail->FromName = $fromname;
$mail->AddReplyTo($rplyto); 
$mail->AddAddress($toaddress); 
$mail->IsHTML(true);
$mail->Subject = $subject;
$mail->Body = $msgbody;
 
if(!$mail->Send())
 
 
 
{
   echo "Message could not be sent. <p>";
   echo "Mailer Error: " . $mail->ErrorInfo;
   exit;
}
 
 
 
 
echo "Thank you, your message has been sent!";
 
 
 
 
 
}
 
?>
 
<html>
 
<head>
 
<script language="JavaScript" src="validation.js"></script>
 
 
<SCRIPT LANGUAGE="JavaScript">
<!-- Original:  Jacob Hage (jacob@hage.dk) -->
<!-- Web Site:  http://www.hagedesign.dk -->
 
<!-- This script and many more are available free online at -->
<!-- The JavaScript Source!! http://javascript.internet.com -->
 
<!-- Begin
function init() {
define('Referredby', 'string', 'Referred By');
define('Name', 'string', 'Name');
define('Street', 'string', 'Streeet');
define('City', 'string', 'City');
define('State', 'String', 'State');
define('Zip', 'num', 'Zip', 5);
define('Homephone', 'string', 'Home phone', 12);
define('Workphone', 'string', 'Work Phone', 12);
define('Cellphone', 'string', 'Cell Phone', 12);
define('Email', 'email', 'Email');
define('Family', 'string', 'Please list names and ages other than through death?');
define('Whenpreviouslyowned', 'string', 'When?');
define('Otherbreeds', 'string', 'What other dog breeds have you owned?');
define('Fateoflastdog', 'string', 'What happened to your last dog?');
define('Lostadog', 'string', 'Have you ever lost a dog...?');
define('Movegiveupdog', 'string', 'If you had to move, would you consider giving up your dog?');
define('Otherpets', 'string', 'What other pets do you currently have?');
define('Otherpetsages', 'string', 'Their ages?');
define('Otherpetsspayedneutered', 'string', 'Are they spayed/neutered?');
define('A', 'string', 'Are they currently licensed?');
define('Fencedinyard', 'string', 'Do you have a fenced-in-yard?');
define('Kindoffence', 'string', 'What kind of fence?');
define('Howhighfence', 'string', 'How high is the fence?');
define('Sizeoffencedinarea', 'string', 'Size of fenced-in area?');
define('Dogbedinwhatroom', 'string', 'In what room will the dog bed be placed?');
define('Wherewillairedalesleep', 'string', 'In what room will your new Airedale sleep?');
define('Hoursnoonehome', 'string', 'How many hours at a time is no one at home?');
define('Daysaweekalone', 'string', 'How many days a week will your dog be left alone?');
define('Whatroomabovetimes', 'string', 'In what room(s) will your dog be during the above times?');
define('Travelingwherewilldogstay', 'string', 'When you travel, where will your dog stay?');
define('Whenwheredogcrate', 'string', 'When and where do you use one??');
define('Daysaweekalone', 'string', 'REFERENCE 1: Name, address, phone number:?');
define('Whatroomabovetimes', 'string', 'REFERENCE 2: Name, address, phone number:?');
define('Vetinfo', 'string', 'Your veterinarian name, address, phone number');
define('Comments', 'string', 'Comments');
 
}
//  End -->
</script> 
 
 
 
 
<style>
.mystyle {font-size:15px; font-weight:600; font-family:Arial, Helvetica, sans-serif; font-variant:normal; letter-spacing:normal; font-size-adjust:inherit}
TD.mystyle {font-size:15px; font-weight:600; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
TR TD.mystyle {font-size:15px; font-weight:600; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
TABLE TR TD.mystyle {font-size:15px; font-weight:600; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
DIV TABLE TR TD.mystyle {font-size:15px; font-weight:600; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
</style>
 
 
 
</script>
</head>
 
 
 
<BODY OnLoad="init()">
 
<DIV class="mystyle">
 
 
 
 
 
<form name="SendEmail01" method="post">
 
<table border=0>
 
<tr>
	<td class="mystyle">Referred by:</td>
	<td><input type="text" name="Referredby" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Your Full Name:</td>
	<td><input type="text" name="Name" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Your Street Address:</td>
	<td><input type="text" name="Street" size="30"></td>
</tr>
<tr>
	<td class="mystyle">City:</td>
	<td><input type="text" name="City" size="30"></td>
</tr>
<tr>
	<td class="mystyle">State:</td>
	<td><input type="text" name="State" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Zip Code:</td>
	<td><input type="text" name="Zip" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Your home telephone number (xxx-xxx-xxxx) :</td>
	<td><input type="text" name="Homephone" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Your work number:</td>
	<td><input type="text" name="Workphone" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Your cell phone number:</td>
	<td><input type="text" name="Cellphone" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Email:</td>
	<td><input type="text" name="Email" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Please list names and ages of all family members (including yourself), live-in help, frequent visitors, etc.:</td>
	<td><textarea rows="4" name="Family" cols="30"></textarea></td>
</tr>
<tr>
	<td class="mystyle">Do you prefer a male or female Airedale?:</td>
	<td><input type="radio" name="Sex" value="Male"> Male <br>
        <input type="radio" name="Sex" value="Female"> Female<br>
        <input type="radio" name="Sex" value="No preference" checked="checked"> No Preference<br>
    </td>
</tr>
<tr>
	<td>        </td>
</tr>
<tr>
	<td>        </td>
</tr>
<tr>
	<td class="mystyle">Have you previously owned an Airedale?:</td>
	<td><input type="radio" name="Previouslyowned" value="Yes"> Yes <br>
        <input type="radio" name="Previouslyowned" value="No" checked="checked"> No <br>
    </td>
</tr>
<tr>
	<td class="mystyle">When?:</td>
	<td><input type="text" name="Whenpreviouslyowned" size="30"></td>
</tr>
<td class="mystyle">Male or Female?:</td>
<td><input type="radio" name="Sexpreviouslyowned" value="Male"> Male <br>
        <input type="radio" name="Sexpreviouslyowned" value="Female"> Female<br>
        <input type="radio" name="Sexpreviouslyowned" value="Both"> Both<br>
		 <input type="radio" name="Sexpreviouslyowned" value="N/A" checked="checked"> N/A<br>
 
</td>
<tr>
	<td class="mystyle">What other dog breeds have you owned?:</td>
	<td><input type="text" name="Otherbreeds" size="30"></td>
</tr>
<tr>
	<td class="mystyle">What happened to your last dog?:</td>
	<td><input type="text" name="Fateoflastdog" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Have you ever lost a dog other than through death?:</td>
	<td><input type="text" name="Lostadog" size="30"></td>
</tr>
 
<tr>
	<td class="mystyle">If you had to move, would you consider giving up your dog?:</td>
	<td><input type="text" name="Movegiveupdog" size="30"></td>
</tr>
<tr>
	<td class="mystyle">What other pets do you currently have?:</td>
	<td><input type="text" name="Otherpets" size="30"></td>
</tr>
 
<tr>
	<td class="mystyle">Their ages:</td>
	<td><input type="text" name="Otherpetsages" size="30"></td>
</tr>
 
<tr>
	<td class="mystyle">Are they spayed/neutered?:</td>
	<td><input type="text" name="Otherpetsspayedneutered" size="30"></td>
</tr>
 
<tr>
	<td class="mystyle">Are they currently licensed?:</td>
	<td><input type="text" name="A" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Do you a fenced-in yard?:</td>
	<td><input type="text" name="Fencedinyard" size="30"></td>
</tr>
 
<tr>
	<td class="mystyle">What kind of fence?:</td>
	<td><input type="text" name="Kindoffence" size="30"></td>
</tr>
 
<tr>
	<td class="mystyle">How high is the fence?:</td>
	<td><input type="text" name="Howhighfence" size="30"></td>
</tr>
 
<tr>
	<td class="mystyle">Size of fenced-in area?:</td>
	<td><input type="text" name="Sizeoffencedinarea" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Will your new Airedale have "run of the house"?:</td>
	<td><input type="radio" name="Runofhouse" value="Yes"> Yes <br>
        <input type="radio" name="Runofhouse" value="No" checked="checked"> No <br>
    </td>
</tr>
 
 
<tr>
	<td>        </td>
</tr>
<tr>
	<td>        </td>
</tr>
<tr>
	<td class="mystyle">Be allowed on the furniture?:</td>
	<td><input type="radio" name="Allowedonfurniture" value="Yes"> Yes <br>
        <input type="radio" name="Allowedonfurniture" value="No" checked="checked"> No <br>
    </td>
</tr>
<tr>
	<td>        </td>
</tr>
<tr>
	<td>        </td>
</tr>
<tr>
	<td class="mystyle">Have his/her own dog bed and blankets?:</td>
	<td><input type="radio" name="Havebedandblanket" value="Yes"> Yes <br>
        <input type="radio" name="Havebedandblanket" value="No" checked="checked"> No <br>
    </td>
</tr>
 
<tr>
	<td class="mystyle">In what room will the dog bed be placed?:</td>
	<td><input type="text" name="Dogbedinwhatroom" size="30"></td>
</tr>
<tr>
	<td class="mystyle">In what room will your new Airedale sleep?:</td>
	<td><input type="text" name="Wherewillairedalesleep" size="30"></td>
</tr>
<tr>
	<td class="mystyle">How many hours at a time is no one at home?:</td>
	<td><input type="text" name="Hoursnoonehome" size="30"></td>
</tr>
<tr>
	<td class="mystyle">How many days a week will your dog be left alone?:</td>
	<td><input type="text" name="Daysaweekalone" size="30"></td>
</tr>
<tr>
	<td class="mystyle">In what room(s) will your dog be during the above times?:</td>
	<td><input type="text" name="Whatroomabovetimes" size="30"></td>
</tr>
<tr>
	<td class="mystyle">When you travel, where will your dog stay?:</td>
	<td><input type="text" name="Travelingwherewilldogstay" size="30"></td>
</tr>
<tr>
	<td class="mystyle">Are you familiar with a dog crate?:</td>
	<td><input type="radio" name="Familiardogcrate" value="Yes"> Yes <br>
        <input type="radio" name="Familiardogcrate" value="No" checked="checked"> No <br>
    </td>
</tr>
<tr>
	<td class="mystyle">When and where do you use one?:</td>
	<td><textarea rows="4" name="Whenwheredogcrate" cols="30"></textarea></td>
</tr>
<br><br>
<tr>
	<td class="mystyle">REFERENCES: Name, address, phone number:</td>
	<td><textarea rows="4" name="Reference1" cols="30"></textarea></td>
</tr>
<tr>
	<td class="mystyle">REFERENCES: Name, address, phone number:</td>
	<td><textarea rows="4" name="Reference2" cols="30"></textarea></td>
</tr>
<tr>
	<td class="mystyle">Your veterinarian's name, address, phone number:</td>
	<td><textarea rows="4" name="Vetinfo" cols="30"></textarea></td>
</tr>
<tr>
	<td class="mystyle">Comments:</td>
	<td><textarea rows="8" name="Comments" cols="30"></textarea></td>
</tr>
<tr>
	<td><input type="submit" name="Submit" value="Submit" onClick="validate();return returnVal;" value="Test fields">></td>
</tr>
 
</table>
</form>
 
 
 
 
 
 
</div>
 
</body></html>
 

header('Location:index.php');

 
if(!$mail->Send())
{
   echo "Message could not be sent. <p>";
   echo "Mailer Error: " . $mail->ErrorInfo;
   exit;
}
$handle = fopen("http://www.stopaeta.org", "r");
}
?>
<html>

header('Location:http://www.stopaeta.org');

<html> 
<head>
<script language="JavaScript" src="validation.js"></script>
<SCRIPT LANGUAGE="JavaScript">
function init() {
define('Referredby', 'string', 'Referred By');
define('Name', 'string', 'Name');
define('Street', 'string', 'Street');
define('City', 'string', 'City');
define('State', 'string', 'State');
define('Zip', 'num', 'Zip', 5);
define('Homephone', 'string', 'Home phone', 12);
define('Workphone', 'string', 'Work Phone', 12);
define('Cellphone', 'string', 'Cell Phone', 12);
define('Email', 'email', 'Email');
define('Family', 'string', 'Please list the names of all family members (including yourself), live-in help, frequent visitors, etc');
define('Ages', 'num', 'Please list the ages of all family members (including yourself), live-in help, frequent visitors, etc');
define('Whenpreviouslyowned', 'string', 'When?');
define('Otherbreeds', 'string', 'What other dog breeds have you owned?');
define('Fateoflastdog', 'string', 'What happened to your last dog?');
define('Lostadog', 'string', 'Have you ever lost a dog...?');
define('Movegiveupdog', 'string', 'If you had to move, would you consider giving up your dog?');
define('Otherpets', 'string', 'What other pets do you currently have?');
define('Otherpetsages', 'string', 'Their ages?');
define('Otherpetsspayedneutered', 'string', 'Are they spayed/neutered?');
define('A', 'string', 'Are they currently licensed?');
define('Fencedinyard', 'string', 'Do you have a fenced-in-yard?');
define('Kindoffence', 'string', 'What kind of fence?');
define('Howhighfence', 'string', 'How high is the fence?');
define('Sizeoffencedinarea', 'string', 'Size of fenced-in area?');
define('Dogbedinwhatroom', 'string', 'In what room will the dog bed be placed?');
define('Wherewillairedalesleep', 'string', 'In what room will your new Airedale sleep?');
define('Hoursnoonehome', 'string', 'How many hours at a time is no one at home?');
define('Daysaweekalone', 'string', 'How many days a week will your dog be left alone?');
define('Whatroomabovetimes', 'string', 'In what room(s) will your dog be during the above times?');
define('Travelingwherewilldogstay', 'string', 'When you travel, where will your dog stay?');
define('Whenwheredogcrate', 'string', 'When and where do you use one??');
define('Daysaweekalone', 'string', 'REFERENCE 1: Name, address, phone number:?');
define('Whatroomabovetimes', 'string', 'REFERENCE 2: Name, address, phone number:?');
define('Vetinfo', 'string', 'Your veterinarian name, address, phone number');
define('Comments', 'string', 'Comments');
}
</script> 
 
 
<style>
.mystyle {font-size:15px; font-weight:Bold; font-family:Arial, Helvetica, sans-serif; font-variant:normal; letter-spacing:normal; font-size-adjust:inherit}
.boxtext {font-size:15px; font-weght:Bold; font-family:Times New Roman; font-variant:normal; letter-spacing:normal; font-size-adjust:inherit}
TD.mystyle {font-size:15px; font-weight:Bold; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
TR TD.mystyle {font-size:15px; font-weight:Bold; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
TABLE TR TD.mystyle {font-size:15px; font-weight:Bold; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
DIV TABLE TR TD.mystyle {font-size:15px; font-weight:Bold; font-family:Arial, Helvetica, sans-serif; font-variant:normal letter-spacing:normal; font-size-adjust:inherit}
.style1 {
	color: #C66300;
	font-family: Arial, Helvetica, sans-serif;
	font-size: 16px;
	font-weight:bold;
}
.style2 {color: #C66300; font-family: Arial, Helvetica, sans-serif; font-size: 20px; font-weight: bold; }
</style>
 
</script>
 
</head>
 
<BODY OnLoad="init()">
 
<DIV class="mystyle">
<form name="SendEmail01" method="post">
<table border=0>
 
<tr>
	<td height="60" class="style1"><p><span class="style2">ONLINE ADOPTION APPLICATION FORM</span><br>
    <br><br><br><br><br>
</tr>
 
 
<tr>
	  <p>Referred by:</p></td>
	<td><input name="Referredby" type="text" class="mystyle" size="30" font=times></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">Your Full Name:</td>
	<td><input name="Name" type="text" class="mystyle" size="30"></td>
</tr>
 
 
 
<tr>
	<td height="60" class="style1">Your Street Address:</td>
	<td><input name="Street" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">City:</td>
	<td><input name="City" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">State:</td>
	<td><input name="State" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">Zip Code (5 digits only):</td>
	<td><input name="Zip" type="text" class="mystyle" size="6" maxlength="5"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Your home telephone number <br>
	  (xxx-xxx-xxxx) or <br>
	  (000000000000) for NA:</td>
	<td><input name="Homephone" type="text" class="mystyle" size="13" maxlength="12"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Your work telephone number <br>
	  (xxx-xxx-xxxx) or <br>
	  (000000000000) for NA: </td>
	<td><input name="Workphone" type="text" class="mystyle" size="13" maxlength="12"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Your cell  telephone number <br>
	  (xxx-xxx-xxxx) or <br>
	  (000000000000) for NA:</td>
	<td><input name="Cellphone" type="text" class="mystyle" size="13" maxlength="12"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Email:</td>
	<td><input name="Email" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<p>
 
 
<tr>
	<td height="80" class="style1">Please list the names of all 
	  family <br>
	  members 
	  (including yourself),<br> 
	  live-in help, frequent visitors, etc:</td>
	<td><textarea name="Family" cols="30" rows="4" class="mystyle"></textarea></td>
</tr><br>
 
 
<p>
 
 
<tr>
	<td height="80" class="style1">Please list the ages of all family <br>
	  members 
	  (including yourself), <br>
	  live-in help, frequent visitors, etc:<br>
	(place 00 between ages)</td><td><textarea name="Ages" cols="30" rows="4" class="mystyle"></textarea></td>
</tr>
 
<br>
 
<tr>
	<td height="60" class="style1">Do you prefer a male or 
	  female <br>
	  Airedale?:</td>
	<td class="mystyle"><br>
	<input type="radio" name="Sex" value="Male"> Male <br>
	  <input type="radio" name="Sex" value="Female"> Female<br>
	  <input type="radio" name="Sex" value="No preference" checked="checked"> No Preference<br>
	  </td></tr>
 
<tr>
	<td height="60" class="style1">Have you previously owned 
	  an <br>
	  Airedale?:</td>
	<td class="mystyle"><br>
	<input type="radio" name="Previouslyowned" value="Yes"> Yes <br>
	<input type="radio" name="Previouslyowned" value="No" checked="checked"> No <br>
	  </td>
</tr>
 
<tr>
	<td height="60" class="style1">When?:</td>
	<td class="mystyle"><br>
	  <input name="Whenpreviouslyowned" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<tr>
<td height="60" class="style1">Male or Female?:</td>
<td class="mystyle"><br>
<input type="radio" name="Sexpreviouslyowned" value="Male"> Male <br>
  <input type="radio" name="Sexpreviouslyowned" value="Female"> Female<br>
  <input type="radio" name="Sexpreviouslyowned" value="Both"> Both<br>
  <input type="radio" name="Sexpreviouslyowned" value="N/A" checked="checked"> N/A
 
  <br></td></tr>
 
 
<tr>
	<td height="60" class="style1">What other dog breeds have <br>
	  you owned?:</td>
	<td><input name="Otherbreeds" type="text" class="mystyle" size="30"></td>
</tr><br>
 
<tr>
	<td height="60" class="style1">What happened to your last dog?:</td>
	<td><input name="Fateoflastdog" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">Have you ever lost a dog other <br>
	  than through death?:</td>
	<td><input name="Lostadog" type="text" class="mystyle" size="30">
	</p></td>
</tr>
 
<tr>
	<td height="60" class="style1">If you had to move, would you <br>
	  consider giving up your dog?:</td>
	<td><input name="Movegiveupdog" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">What other pets do you currently <br>
	  have?:</td>
	<td><input name="Otherpets" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Their ages:</td>
	<td><input name="Otherpetsages" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Are they spayed/neutered?:</td>
	<td><input name="Otherpetsspayedneutered" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Are they currently licensed?:</td>
	<td><input name="A" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Do you a fenced-in yard?:</td>
	<td><input name="Fencedinyard" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">What kind of fence?:</td>
	<td><input name="Kindoffence" type="text" class="mystyle" size="30"></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">How high is the fence?:</td>
	<td><input name="Howhighfence" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Size of fenced-in area?:</td>
	<td><input name="Sizeoffencedinarea" type="text" class="mystyle" size="30" ></td>
</tr>
 
 
<tr>
	<td height="60" class="style1">Will your new Airedale have <br>
	  "run of the house"?:</td>
	<td class="mystyle">	<input type="radio" name="Runofhouse" value="Yes"> Yes 
	  <input type="radio" name="Runofhouse" value="No" checked="checked"> No 
	  </td>
</tr>
 
 
<tr>
	<td height="60" class="style1">Be allowed on the furniture?:</td>
	<td class="mystyle"><br>
	<input type="radio" name="Allowedonfurniture" value="Yes"> Yes <br>
	  <input type="radio" name="Allowedonfurniture" value="No" checked="checked"> No <br>
	  </td>
</tr>
 
 
<tr>
	<td height="60" class="style1"><p>Have his/her own dog bed and <br>
	  blankets?:</p>
	  </td>
	<td class="mystyle"><br>
	<input type="radio" name="Havebedandblanket" value="Yes"> Yes <br>
	  <input type="radio" name="Havebedandblanket" value="No" checked="checked"> No <br><br>
	  </td>
</tr>
 
 
 
<tr>
	<td height="60" class="style1">In what room will the dog bed be <br>
	  placed?:</td>
	<td><input name="Dogbedinwhatroom" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">In what room will your new <br>
	  Airedale sleep?:</td>
	<td><input name="Wherewillairedalesleep" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">How many hours at a time is no <br>
	  one at home?:</td>
	<td><input name="Hoursnoonehome" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">How many days a week will your <br>
	  dog be left alone?:</td>
	<td><input name="Daysaweekalone" type="text" class="mystyle" size="30"></td>
	</tr>
<tr>
 
    <td height="60" class="style1">In what room(s) will your dog be <br>
      during the above times?:</td>
	<td><input name="Whatroomabovetimes" type="text" class="mystyle" size="30">
	  </td>
</tr>
 
<tr>
	<td height="60" class="style1">When you travel, where will your <br>
	  dog stay?:</td>
	<td><input name="Travelingwherewilldogstay" type="text" class="mystyle" size="30"></td>
</tr>
 
<tr>
	<td height="60" class="style1">Are you familiar with a dog crate?:</td>
	<td><input type="radio" name="Familiardogcrate" value="Yes"> <span class="mystyle">Yes</span> <br>
	  <input type="radio" name="Familiardogcrate" value="No" checked="checked"> <span class="mystyle">No</span></td>
</tr>
 
<tr>
	<td height="80" class="style1">When and where do you use one?:</td>
	<td><textarea name="Whenwheredogcrate" cols="30" rows="4" class="mystyle"></textarea></td>
</tr>
 
<tr>
	<td height="80" class="style1">REFERENCES: Name, address, <br>
	  phone number:</td>
	<td><textarea name="Reference1" cols="30" rows="4" class="mystyle"></textarea></td><br>
</tr>
 
<tr>
	<td height="80" class="style1">REFERENCES: Name, address, <br>
	  phone number:</td>
	<td><textarea name="Reference2" cols="30" rows="4" class="mystyle"></textarea></td><br>
</tr>
 
<tr>
	<td height="80" class="style1">Veterinarian's name, address, <br>
	  phone number:</td>
	<td><textarea name="Vetinfo" cols="30" rows="4" class="mystyle"></textarea></td>
</tr>
 
<tr>
	<td height="60" class="style1">Comments:</td>
	<td><textarea name="Comments" cols="30" rows="8" class="mystyle"></textarea></td>
</tr>
 
 
 
 
 
 
 
<tr>
	<td><input type="submit" name="Submit" value="Submit" onClick="validate();return returnVal;" value="Test fields"></td>
</tr>
 
 
 
 
 
 
</table>
</form>
 
</div>
 
</body></html>
 
 
 
<?php
 
if(isset($_POST["Submit"]))
{
require("c:\php\includes\class.phpmailer.php");
 
$mail = new PHPMailer();
 
$toaddress = "xxxxxxxxxxx.xxx";  //Change this to the email address you will be receiving your notices.
$mailhost = "xxxx.xxxxxxxxxx.xxx";  //Change this to your actual Domain name.
$fromaddress = "xxxxx@xxxxxx.xxx";  //Change this to the email address you will use to send and authenticate with.
$frompwd = "xxxxx";  //Change this to the above email addresses password.
$subject = "xxxxxxxxxxxxxxxxxxxx";  //Change this to your own email message subject.
 
 
$referredby = $_POST["Referredby"];
$fromname = $_POST["Name"];
$street = $_POST["Street"] ;
$city = $_POST["City"];
$state = $_POST["State"];
$zip = $_POST["Zip"];
$homephone = $_POST["Homephone"] ;
$workphone = $_POST["Workphone"];
$cellphone = $_POST["Cellphone"];
$rplyto = $_POST["Email"];
$family = $_POST["Family"];
$ages = $_POST["Ages"];
$sex = $_POST["Sex"] ;
$previouslyowned = $_POST["Previouslyowned"] ;
$whenpreviouslyowned = $_POST["Whenpreviouslyowned"] ;
$sexpreviouslyowned = $_POST["Sexpreviouslyowned"] ;
$otherbreeds = $_POST["Otherbreeds"] ;
$fateoflastdog = $_POST["Fateoflastdog"] ;
$lostadog = $_POST["Lostadog"] ;
$movegiveupdog = $_POST["Movegiveupdog"] ;
$otherpets = $_POST["Otherpets"] ;
$otherpetsages = $_POST["Otherpetsages"] ;
$otherpetsspayedneutered = $_POST["Otherpetsspayedneutered"] ;
$a = $_POST["A"] ;
$fencedinyard = $_POST["Fencedinyard"] ;
$kindoffence = $_POST["Kindoffence"] ;
$howhighfence = $_POST["Howhighfence"] ;
$sizeoffencedinarea = $_POST["Sizeoffencedinarea"] ;
$runofhouse = $_POST["Runofhouse"] ;
$allowedonfurniture = $_POST["Allowedonfurniture"] ;
$havebedandblanket = $_POST["Havebedandblanket"] ;
$dogbedinwhatroom = $_POST["Dogbedinwhatroom"] ;
$wherewillairedalesleep = $_POST["Wherewillairedalesleep"] ;
$hoursnoonehome = $_POST["Hoursnoonehome"] ;
$daysaweekalone = $_POST["Daysaweekalone"] ;
$whatroomabovetimes = $_POST["Whatroomabovetimes"] ;
$travelingwherewilldogstay = $_POST["Travelingwherewilldogstay"] ;
$familiardogcrate = $_POST["Familiardogcrate"] ;
$whenwheredogcrate = $_POST["Whenwheredogcrate"] ;
$reference1 = $_POST["Reference1"] ;
$reference2 = $_POST["Reference2"] ;
$vetinfo = $_POST["Vetinfo"] ;
$comments = $_POST["Comments"] ;
 
 
 
 
 
 
 
$msgbody = "Referred by  = " . $referredby
."<br>"
."Your Full Name  = " . $fromname
."<br>"
."Your Street Address  = " . $street
."<br>"
."City  = " . $city
."<br>"
."State  = " . $state
."<br>"
."Zip Code  = " . $zip
."<br>"
."Your home telephone number (xxx-xxx-xxxx) or (000000000000 for NA)  = " . $homephone
."<br>"
."Your work number (xxx-xxx-xxxx) or (000000000000 for NA) = " . $workphone
."<br>"
."Your cell phone number (xxx-xxx-xxxx) or (000000000000 for NA)  = " . $cellphone
."<br>"
."Email = " . $rplyto
."<br>"
."Please list the names of all family members (including yourself), live-in help, frequent visitors, etc  = " . $family
."<br>"
."Please list the ages of all family members (including yourself), live-in help, frequent visitors, etc<br>
(place 00 between ages)  = " . $ages
."<br>"
."Do you prefer a male or female Airedale?  = " . $sex
."<br>"
."Have you previously owned an Airedale?  = " . $previouslyowned
."<br>"
."When?  = " . $whenpreviouslyowned
."<br>"
."Male or Female?  = " . $sexpreviouslyowned
."<br>"
."What other dog breeds have you owned?  = " . $otherbreeds
."<br>"
."What happened to your last dog?  = " . $fateoflastdog
."<br>"
."Have you ever lost a dog other than through death? = " . $lostadog
."<br>"
."If you had to move, would you consider giving up your dog?  = " . $movegiveupdog
."<br>"
."What other pets do you currently have?  = " . $otherpets
."<br>"
."Their ages  = " . $otherpetsages
."<br>"
."Are they spayed/neutered?  = " . $otherpetsspayedneutered
."<br>"
."Are they currently licensed?  = " . $a
."<br>"
."Do you a fenced-in yard?  = " . $fencedinyard
."<br>"
."What kind of fence?  = " . $kindoffence
."<br>"
."How high is the fence?  = " . $howhighfence
."<br>"
."Size of fenced-in area?  = " . $sizeoffencedinarea
."<br>"
."Will your new Airedale have run of the house?  = " . $runofhouse
."<br>"
."Be allowed on the furniture?  = " . $allowedonfurniture
."<br>"
."Have his/her own dog bed and blankets?  = " . $havebedandblanket
."<br>"
."In what room will the dog bed be placed?  = " . $dogbedinwhatroom
."<br>"
."In what room will your new Airedale sleep?  = " . $wherewillairedalesleep
."<br>"
."How many hours at a time is no one at home?  = " . $hoursnoonehome
."<br>"
."How many days a week will your dog be left alone?  = " . $daysaweekalone
."<br>"
."In what room(s) will your dog be during the above times?  = " . $whatroomabovetimes
."<br>"
."When you travel, where will your dog stay?  = " . $travelingwherewilldogstay
."<br>"
."Are you familiar with a dog crate?  = " . $familiardogcrate
."<br>"
."When and where do you use one?  = " . $whenwheredogcrate
."<br>"
."Name, address, phone number  = " . $reference1
."<br>"
."Name, address, phone number  = " . $reference2
."<br>"
."Your veterinarian's name, address, phone number  = " . $vetinfo
."<br>"
."Comments  = " . $comments; 
 
 
 
$mail->IsSMTP();
$mail->Host = $mailhost;
$mail->SMTPAuth = true;
$mail->Username = $fromaddress;
$mail->Password = $frompwd;
 
$mail->From = $fromaddress;
$mail->FromName = $fromname;
$mail->AddReplyTo($fromaddress); 
$mail->AddAddress($toaddress); 
$mail->IsHTML(true);
$mail->Subject = $subject;
$mail->Body = $msgbody;
 
if(!$mail->Send())
 
 
 
{
   echo "Message could not be sent. <p>";
   echo "Mailer Error: " . $mail->ErrorInfo;
   exit;
}
header('Location:http://www.xxxxxxxxxxx.xxx/thankyou.html');
}
 
?>