<!-- The contact form starts from here-->
<?php $error = ''; // error message
$fname = ''; // sender's name
$lname = ''; // sender's name
$email = ''; // sender's email address
$myspace = ''; // myspace
$client = ''; // IM Client
$screenname = ''; // IM screen name
$service = ''; // service
$phone = ''; // address
$address = ''; // address
$city = ''; // address
$state = ''; // address
$country = ''; // address
$zip = ''; // zip code
$tos = ''; // agree to terms of service
if(isset($_POST['send']))
{$fname = $_POST['fname'];
$lname = $_POST['lname'];
$email = $_POST['email'];
$myspace = $_POST['myspace'];
$client = $_POST['client'];
$screenname = $_POST['screenname'];
$service = $_POST['service'];
$phone = $_POST['phone'];
$address = $_POST['address'];
$city = $_POST['city'];
$state = $_POST['state'];
$country = $_POST['country'];
$zip = $_POST['zip'];
$tos = $_POST['tos'];
$ip = $_POST['ip'];
if(trim($fname) == '')
{
$error = '<div class="errormsg">Please enter your first name!</div>';
}
if(trim($lname) == '')
{
$error = '<div class="errormsg">Please enter your last name!</div>';
}
else if(trim($email) == '')
{
$error = '<div class="errormsg">Please enter your email address!</div>';
}
else if(!isEmail($email))
{
$error = '<div class="errormsg">Invalid Email address, Try Again!</div>';
}
if(trim($myspace) == '')
{
$error = '<div class="errormsg">Please enter you MySpace URL</div>';
}
if(trim($client) == '')
{
$error = '<div class="errormsg">Please SELECT an IM Client!</div>';
}
if(trim($screenname) == '')
{
$error = '<div class="errormsg">Please enter your IM screen name!</div>';
}
if(trim($service) == '')
{
$error = '<div class="errormsg">Please SELECT a Service!</div>';
}
if(trim($address) == '')
{
$error = '<div class="errormsg">Please enter your address!</div>';
}
if(trim($phone) == '')
{
$error = '<div class="errormsg">Please enter your Phone Number (USA EX: 19996382764)</div>';
}
if(trim($zip) == '')
{
$error = '<div class="errormsg">Please enter your zip code!</div>';
}
if(trim($tos) == '')
{
$error = '<div class="errormsg">Please agree to MDT(CSMI) Terms of USE/Privacy Policy!</div>';
}
if($error == '')
{
if(get_magic_quotes_gpc())
{
$message = stripslashes($message);
}
// the email will be sent here
// make sure to change this to be your e-mail
$to = "MDT@mycsmi.org";
// the email subject
// '[Contact Form] :' will appear automatically in the subject.
// You can change it as you want
$subject = 'MDT(CHRISTSPACE) Service Request!';
// the mail message ( add any additional information if you want )
$msg = "From : $fname $lname \r\nAccount Number: $id\r\nE-Mail : $email \r\nMySpace : $myspace \r\nIM 24/7 : $client | $screenname \r\nMinistry Service : $service \r\nPhone: $phone \r\nAddress : $address $city, $state $zip, $country \r\nAgree To MDT(CSMI) TOS : $tos";
mail($to, $subject, $msg, "From: $email\r\nReply-To: $email\r\nReturn-Path: $email\r\n");
?>
<!-- Message sent! (change the text below as you wish)-->
<div style="text-align:center;"><table width="500" height="105" border="0">
<tr><td height="101"><h5 align="center" class="style38 style8 style8 style8 style55">Welcome to MDT International </h5>
<h5 align="center" class="style1 style8 style8 style8">Thank you <?=$fname;?> <?=$lname;?> , we have recieved your <br>
Service Request Application!<br>
<br>WE WILL RESPOND WITHIN 15 HOURS! </h5></td>
</tr></table></div><p><!--End Message Sent-->
<?php
}
}
if(!isset($_POST['send']) || $error != '')
{
?></p>
<table width="516" border="0" align="center">
<tr><td><div align="center" class="style49"><?=$error;?></div></td> </tr></table>
<form method="post" name="contFrm" id="contFrm" onSubmit="return jcap();">
<table width="516" height="376" border="0" align="center">
<tr>
<td width="145" height="36"><div class="float-left"><strong><span class="required">*</span> First/Last Name:</strong></div></td>
<td width="384"><input name="fname" type="text" class="box" id="fname" size="23" value="<?=$fname;?>" />
<input name="lname" type="text" class="box" id="lname" size="23" value="<?=$lname;?>" /></td></tr>
<tr><td width="145" height="36"><div class="float-left"><strong><span class="required">*</span> Email: </strong></div></td>
<td><input name="email" type="text" class="box" id="email" size="30" value="<?=$email;?>" /></td></tr>
<tr><td width="145" height="36"><div class="float-left"><strong><span class="required">*</span> MySpace URL: </strong></div></td>
<td>myspace.com/<input name="myspace" type="text" class="box" id="myspace" size="30" value="<?=$myspace;?>" />
<a href="extras/LifePoint/viewtopic.php?f=31&t=11">WANT 1 </a></td>
</tr>
<tr><td width="145" height="36"><div class="float-left"><strong><span class="required">* </span>IM 24/7 : </strong></div></td>
<td><select name="client" id="client">
<option value="AOL AIM" selected>AOL AIM</option>
<option value="Google Talk">Google Talk</option>
<option value="MSN Live">MSN Live</option>
<option value="MySpace IM">MySpace IM</option>
<option value="Yahoo! IM">Yahoo! IM</option>
</select>
|
<input name="screenname" type="text" class="box" id="screenname" size="20" value="<?=$screenname;?>" /></td></tr>
<tr><td height="34"><div class="float-left"><strong><span class="required">*</span> Ministry Service: </strong></div></td>
<td><select name="service" id="service">
<option value="MDT(CSMI)" selected>MDT(CHRISTSPACE)</option>
<option value="IM 24/7">IM 24/7</option>
<option value="NSR">NO SHAME</option>
<option value="FICA(GOTCHRIST)">FICAMAIL</option>
<option value="MINISTRYKONNECT">MINISTRYKONNECT</option>
<option value="T3 STREET">T3 STREET</option>
<option value="MYSPACE">MYSPACE</option>
<option value="VOLUNTEER">MDT(CSMI) VOLUNTEER</option>
</select>
<a href="extras/LifePoint/">MORE DETAILS ... </a></td></tr>
<tr><td width="145" height="36"><div class="float-left"><strong><span class="required">*</span> Phone Number: </strong></div></td>
<td><input name="phone" type="text" class="box" id="phone" value="<?=$phone;?>" size="10" maxlength="10" />
<span class="style46"><strong><a href="services/MKI/">INTERNATIONAL USERS</a> </strong></span></td>
</tr>
<tr><td height="36" valign="top"><div class="float-left"><strong><span class="required">*</span> Address: </strong></div></td>
<td><input name="address" type="text" class="box" id="address" size="30" value="<?=$address;?>" /></td></tr>
<tr><td height="36" valign="top"><div class="float-left"><strong><span class="required">*</span> City, State: </strong></div></td>
<td><p><input name="city" type="text" class="box" id="city" size="20" value="<?=$city;?>" />, <span class="right">
<select class="other" name="state" id="state" onBlur="validate(this,'Required')">
<option>PR</option>
<option>GU</option>
<option>USVI</option>
<option>NMI</option>
<option>--</option>
<option>AL</option>
<option>AK</option>
<option>AR</option>
<option>AZ</option>
<option>CA</option>
<option>CO</option>
<option>CT</option>
<option>DC</option>
<option>DE</option>
<option>FL</option>
<option>GA</option>
<option>HI</option>
<option>ID</option>
<option>IL</option>
<option>IN</option>
<option>IA</option>
<option>KS</option>
<option>KY</option>
<option>LA</option>
<option>ME</option>
<option>MD</option>
<option>MA</option>
<option>MI</option>
<option>MN</option>
<option>MS</option>
<option>MO</option>
<option>MT</option>
<option>NE</option>
<option>NV</option>
<option>NH</option>
<option>NJ</option>
<option>NM</option>
<option>NY</option>
<option>NC</option>
<option>ND</option>
<option>OH</option>
<option>OK</option>
<option>OR</option>
<option>PA</option>
<option>RI</option>
<option>SC</option>
<option>SD</option>
<option>TN</option>
<option>TX</option>
<option>UT</option>
<option>VT</option>
<option>VA</option>
<option>WA</option>
<option>WV</option>
<option>WI</option>
<option>WY</option>
</select></span></td></tr>
<tr><td width="145" height="36" valign="top"><div class="float-left"><strong><span class="required">*</span> Country, ZIP Code: </strong></div></td><td><p><span class="right">
<select class="other" name="country" id="country" onBlur="validate(this,'Required')">
<option selected="selected">United States</option>
<option>Abkhazia</option>
<option>Afghanistan</option>
<option>United Kingdom Akrotiri and Dhekelia</option>
<option>Aland</option>
<option>Albania</option>
<option>Algeria</option>
<option>American Samoa</option>
<option>Andorra</option>
<option>Angola</option>
<option>Anguilla</option>
<option>Antigua and Barbuda</option>
<option>Argentina Argentina</option>
<option>Armenia</option>
<option>Aruba</option>
<option>United Kingdom Ascension Island</option>
<option>Australia</option>
<option>Austria</option>
<option>Azerbaijan</option>
<option>The Bahamas</option>
<option>Bahrain</option>
<option>Bangladesh</option>
<option>Barbados</option>
<option>Belarus</option>
<option>Belgium</option>
<option>Belize</option>
<option>Benin</option>
<option>Bermuda</option>
<option>Bhutan</option>
<option>Bolivia</option>
<option>Bosnia and Herzegovina</option>
<option>Botswana</option>
<option>Brazil</option>
<option>Brunei</option>
<option>Bulgaria</option>
<option>Burkina Faso</option>
<option>Burundi</option>
<option>Cambodia</option>
<option>Cameroon</option>
<option>Canada</option>
<option>Cape Verde</option>
<option>Cayman Islands</option>
<option>Central African Republic</option>
<option>Chad</option>
<option>Chile</option>
<option>People's Republic of China</option>
<option>Republic of China</option>
<option>Christmas Island</option>
<option>Cocos (Keeling) Islands</option>
<option>Colombia</option>
<option>Comoros</option>
<option>Congo</option>
<option>Cook Islands</option>
<option>Costa Rica</option>
<option>C�te d'Ivoire</option>
<option>Croatia</option>
<option>Cuba</option>
<option>Cyprus</option>
<option>Czech Republic</option>
<option>Denmark</option>
<option>Djibouti</option>
<option>Dominica</option>
<option>Dominican Republic</option>
<option>Ecuador</option>
<option>Egypt</option>
<option>El Salvador</option>
<option>Equatorial Guinea</option>
<option>Eritrea</option>
<option>Estonia</option>
<option>Ethiopia</option>
<option>Falkland Islands</option>
<option>Faroe Islands</option>
<option>Fiji</option>
<option>Finland</option>
<option>France</option>
<option>French Polynesia</option>
<option>Gabon</option>
<option>The Gambia</option>
<option>Georgia</option>
<option>Germany</option>
<option>Ghana</option>
<option>Gibraltar</option>
<option>Greece</option>
<option>Greenland</option>
<option>Grenada</option>
<option>Guam</option>
<option>Guatemala</option>
<option>Guernsey</option>
<option>Guinea</option>
<option>Guinea-Bissau</option>
<option>Guyana Guyana</option>
<option>Haiti Haiti</option>
<option>Honduras</option>
<option>Hong Kong</option>
<option>Hungary</option>
<option>Iceland</option>
<option>India</option>
<option>Indonesia</option>
<option>Iran</option>
<option>Iraq</option>
<option>Ireland</option>
<option>Israel</option>
<option>Italy</option>
<option>Jamaica</option>
<option>Japan</option>
<option>Jersey</option>
<option>Jordan</option>
<option>Kazakhstan</option>
<option>Kenya</option>
<option>Kiribati</option>
<option>North Korea</option>
<option>South Korea</option>
<option>Kosovo</option>
<option>Kuwait</option>
<option>Kyrgyzstan</option>
<option>Laos</option>
<option>Latvia</option>
<option>Lebanon</option>
<option>Lesotho</option>
<option>Liberia</option>
<option>Libya</option>
<option>Liechtenstein</option>
<option>Lithuania</option>
<option>Luxembourg</option>
<option>Macau</option>
<option>Macedonia</option>
<option>Madagascar</option>
<option>Malawi</option>
<option>Malaysia</option>
<option>Maldives</option>
<option>Mali</option>
<option>Malta</option>
<option>Marshall Islands</option>
<option>Mauritania</option>
<option>Mauritius</option>
<option>Mayotte</option>
<option>Mexico</option>
<option>Micronesia</option>
<option>Moldova</option>
<option>Monaco</option>
<option>Mongolia</option>
<option>Montenegro</option>
<option>Montserrat</option>
<option>Morocco</option>
<option>Mozambique</option>
<option>Myanmar</option>
<option>Nagorno-Karabakh</option>
<option>Namibia</option>
<option>Nauru</option>
<option>Nepal</option>
<option>Netherlands</option>
<option>Netherlands Antilles</option>
<option>New Caledonia</option>
<option>New Zealand</option>
<option>Nicaragua</option>
<option>Niger</option>
<option>Nigeria</option>
<option>Niue</option>
<option>Norfolk Island</option>
<option>Turkish Republic of Northern Cyprus</option>
<option>Northern Mariana</option>
<option>Norway</option>
<option>Pakistan</option>
<option>Palau</option>
<option>Palestine</option>
<option>Panama</option>
<option>Papua New Guinea</option>
<option>Paraguay</option>
<option>Peru</option>
<option>Philippines</option>
<option>Pitcairn Islands</option>
<option>Poland</option>
<option>Portugal</option>
<option>Transnistria Pridnestrovie</option>
<option>Puerto Rico</option>
<option>Qatar</option>
<option>Romania</option>
<option>Russia</option>
<option>Rwanda</option>
<option>Saint Barthelemy</option>
<option>Saint Helena</option>
<option>Saint Kitts and Nevis</option>
<option>Saint Lucia</option>
<option>Saint Martin</option>
<option>Saint Pierre and Miquelon</option>
<option>Saint Vincent and the Grenadines</option>
<option>Samoa</option>
<option>San Marino</option>
<option>S�o Tom� and Pr�ncipe</option>
<option>Saudi Arabia</option>
<option>Senegal</option>
<option>Serbia</option>
<option>Seychelles</option>
<option>Sierra Leone</option>
<option>Singapore</option>
<option>Slovakia</option>
<option>Slovenia</option>
<option>Solomon Islands</option>
<option>Somalia</option>
<option>Somaliland</option>
<option>South Africa</option>
<option>South Ossetia</option>
<option>Spain</option>
<option>Sri Lanka</option>
<option>Sudan</option>
<option>Suriname</option>
<option>Svalbard</option>
<option>Swaziland</option>
<option>Sweden</option>
<option>Switzerland</option>
<option>Syria</option>
<option>Tajikistan</option>
<option>Tanzania</option>
<option>Thailand</option>
<option>Timor-Leste</option>
<option>Togo</option>
<option>Tokelau</option>
<option>Tonga</option>
<option>Trinidad and Tobago</option>
<option>Tristan da Cunha</option>
<option>Tunisia</option>
<option>Turkey</option>
<option>Turkmenistan</option>
<option>Turks and Caicos Islands</option>
<option>Tuvalu</option>
<option>Uganda</option>
<option>Ukraine</option>
<option>United Arab Emirates</option>
<option>United Kingdom</option>
<option>Uruguay</option>
<option>Uzbekistan</option>
<option>Vanuatu</option>
<option>Vatican City</option>
<option>Venezuela</option>
<option>Vietnam</option>
<option>British Virgin Islands</option>
<option>US Virgin Islands</option>
<option>Wallis and Futuna</option>
<option>Western Sahara</option>
<option>Yemen</option>
<option>Zambia</option>
<option>Zimbabwe</option>
</select>
</span>
<input name="zip" type="text" class="box" id="zip" value="<?=$zip?>" size="5" maxlength="5" /></td></tr>
<tr>
<td height="32"><div class="float-left"><strong><span class="required">*</span> Agree to TOS: </strong></div></td>
<td><label>
<input name="tos" type="checkbox" id="tos" value="Y">
<span class="style46"><strong>YES, I ABIDE BY THE MDT(CSMI) TERMS </strong></span></label></td>
</tr></table>
<input name="send" type="submit" class="button" id="send" value="" onClick="return checkForm();" />
<?php
} else {
$fname = $_POST['fname'];
$lname = $_POST['lname'];
$email = $_POST['email'];
$myspace = $_POST['myspace'];
$client = $_POST['client'];
$screenname = $_POST['screenname'];
$service = $_POST['service'];
$phone = $_POST['phone'];
$address = $_POST['address'];
$city = $_POST['city'];
$state = $_POST['state'];
$country = $_POST['country'];
$zip = $_POST['zip'];
$tos = $_POST['tos'];
$ip = $_POST['ip'];
mysql_query("INSERT INTO `MDT(CSMI)`
(fname, lname, email, myspace, client, screenname, service, phone, address, city, state, country, zip, tos) VALUES ('$fname','$lname','$email','$myspace','$client','$screenname','$service','$phone','$address','$city','$state','$country','$zip','$tos' ) ");
}
?>
<?php
function isEmail($email)
{
return(preg_match("/^[-_.[:alnum:]]+@((([[:alnum:]]|[[:alnum:]][[:alnum:]-]*[[:alnum:]])\.)+(ad|ae|aero|af|ag|ai|al|am|an|ao|aq|ar|arpa|as|at|au|aw|az|ba|bb|bd|be|bf|bg|bh|bi|biz|bj|bm|bn|bo|br|bs|bt|bv|bw|by|bz|ca|cc|cd|cf|cg|ch|ci|ck|cl|cm|cn|co|com|coop|cr|cs|cu|cv|cx|cy|cz|de|dj|dk|dm|do|dz|ec|edu|ee|eg|eh|er|es|et|eu|fi|fj|fk|fm|fo|fr|ga|gb|gd|ge|gf|gh|gi|gl|gm|gn|gov|gp|gq|gr|gs|gt|gu|gw|gy|hk|hm|hn|hr|ht|hu|id|ie|il|in|info|int|io|iq|ir|is|it|jm|jo|jp|ke|kg|kh|ki|km|kn|kp|kr|kw|ky|kz|la|lb|lc|li|lk|lr|ls|lt|lu|lv|ly|ma|mc|md|mg|mh|mil|mk|ml|mm|mn|mo|mp|mq|mr|ms|mt|mu|museum|mv|mw|mx|my|mz|na|name|nc|ne|net|nf|ng|ni|nl|no|np|nr|nt|nu|nz|om|org|pa|pe|pf|pg|ph|pk|pl|pm|pn|pr|pro|ps|pt|pw|py|qa|re|ro|ru|rw|sa|sb|sc|sd|se|sg|sh|si|sj|sk|sl|sm|sn|so|sr|st|su|sv|sy|sz|tc|td|tf|tg|th|tj|tk|tm|tn|to|tp|tr|tt|tv|tw|tz|ua|ug|uk|um|us|uy|uz|va|vc|ve|vg|vi|vn|vu|wf|ws|ye|yt|yu|za|zm|zw)$|(([0-9][0-9]?|[0-1][0-9][0-9]|[2][0-4][0-9]|[2][5][0-5])\.){3}([0-9][0-9]?|[0-1][0-9][0-9]|[2][0-4][0-9]|[2][5][0-5]))$/i"
,$email));
}
?></p>