<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');
}
?>