Created
May 23, 2016 14:36
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<form action="contactengine.php" class="appnitro" enctype="text/plain" id= | |
"form_1133213" method="post" name="form_1133213"> | |
<div class="form_description"></div> | |
<ul> | |
<li id="Name"> | |
<label class="description" for="Name">Name</label> | |
<div> | |
<input class="element text medium" id="Name" maxlength="255" name="Name" | |
type="text" value=""> | |
</div> | |
</li> | |
<li id="Company"> | |
<label class="description" for="Company">Company</label> | |
<div> | |
<input class="element text medium" id="Company" maxlength="255" name= | |
"Company" type="text" value=""> | |
</div> | |
</li> | |
<li id="Email"> | |
<label class="description" for="Email">Email</label> | |
<div> | |
<input class="element text medium" id="Email" maxlength="255" name="Email" | |
type="text" value=""> | |
</div> | |
</li> | |
<li id="Phone"> | |
<label class="description" for="Phone">Phone</label> | |
<div> | |
<input class="element text medium" id="Phone" maxlength="255" name="Phone" | |
type="text" value=""> | |
</div> | |
</li> | |
<li id="City"> | |
<label class="description" for="City">City</label> | |
<div> | |
<input class="element text medium" id="City" maxlength="255" name="City" | |
type="text" value=""> | |
</div> | |
</li> | |
<li id="State"> | |
<label class="description" for="State">State</label> | |
<div> | |
<select class="element select medium" id="State" name="State"> | |
<option selected="selected" value=""> | |
</option> | |
<option value="1"> | |
Alabama | |
</option> | |
<option value="2"> | |
Alaska | |
</option> | |
<option value="3"> | |
Arizona | |
</option> | |
<option value="4"> | |
Arkansas | |
</option> | |
<option value="5"> | |
California | |
</option> | |
<option value="6"> | |
Colorado | |
</option> | |
<option value="7"> | |
Connecticut | |
</option> | |
<option value="8"> | |
Delaware | |
</option> | |
<option value="9"> | |
Florida | |
</option> | |
<option value="10"> | |
Georgia | |
</option> | |
<option value="11"> | |
Hawaii | |
</option> | |
<option value="12"> | |
Idaho | |
</option> | |
<option value="13"> | |
Illinois | |
</option> | |
<option value="14"> | |
Indiana | |
</option> | |
<option value="15"> | |
Iowa | |
</option> | |
<option value="16"> | |
Kansas | |
</option> | |
<option value="17"> | |
Kentucky | |
</option> | |
<option value="18"> | |
Louisiana | |
</option> | |
<option value="19"> | |
Maine | |
</option> | |
<option value="20"> | |
Maryland | |
</option> | |
<option value="21"> | |
Massachusetts | |
</option> | |
<option value="22"> | |
Michigan | |
</option> | |
<option value="23"> | |
Minnesota | |
</option> | |
<option value="24"> | |
Mississippi | |
</option> | |
<option value="25"> | |
Missouri | |
</option> | |
<option value="26"> | |
Montana | |
</option> | |
<option value="27"> | |
Nebraska | |
</option> | |
<option value="28"> | |
Nevada | |
</option> | |
<option value="29"> | |
New Hampshire | |
</option> | |
<option value="30"> | |
New Jersey | |
</option> | |
<option value="31"> | |
New Mexico | |
</option> | |
<option value="32"> | |
New York | |
</option> | |
<option value="33"> | |
North Carolina | |
</option> | |
<option value="34"> | |
North Dakota | |
</option> | |
<option value="35"> | |
Ohio | |
</option> | |
<option value="36"> | |
Oklahoma | |
</option> | |
<option value="37"> | |
Oregon | |
</option> | |
<option value="38"> | |
Pennsylvania | |
</option> | |
<option value="39"> | |
Rhode Island | |
</option> | |
<option value="40"> | |
South Carolina | |
</option> | |
<option value="41"> | |
South Dakota | |
</option> | |
<option value="42"> | |
Tennessee | |
</option> | |
<option value="43"> | |
Texas | |
</option> | |
<option value="44"> | |
Utah | |
</option> | |
<option value="45"> | |
Vermont | |
</option> | |
<option value="46"> | |
Virginia | |
</option> | |
<option value="47"> | |
Washington | |
</option> | |
<option value="48"> | |
West Virginia | |
</option> | |
<option value="49"> | |
Wisconsin | |
</option> | |
<option value="50"> | |
Wyoming | |
</option> | |
</select> | |
</div> | |
</li> | |
<li id="Zip"> | |
<label class="description" for="Zip">Zip code</label> | |
<div> | |
<input class="element text medium" id="Zip" maxlength="255" name="Zip" | |
type="text" value=""> | |
</div> | |
</li> | |
<li id="How"> | |
<label class="description" for="How">How did you hear about us?</label> | |
<div> | |
<select class="element select medium" id="How" name="How"> | |
<option selected="selected" value=""> | |
</option> | |
<option value="1"> | |
Martindale.com | |
</option> | |
<option value="2"> | |
Lawyers.com | |
</option> | |
<option value="3"> | |
Press release | |
</option> | |
<option value="4"> | |
Video | |
</option> | |
<option value="5"> | |
Yahoo | |
</option> | |
<option value="6"> | |
MSN | |
</option> | |
<option value="7"> | |
Internet search | |
</option> | |
<option value="8"> | |
Publication | |
</option> | |
<option value="9"> | |
Recent case | |
</option> | |
<option value="10"> | |
Referral | |
</option> | |
</select> | |
</div> | |
</li> | |
<li id="contacted"> | |
<label class="description" for="contacted">How would you like to be | |
contacted?</label> | |
<div> | |
<select class="element select medium" id="contacted" name="contacted"> | |
<option selected="selected" value=""> | |
</option> | |
<option value="1"> | |
Phone | |
</option> | |
<option value="2"> | |
</option> | |
</select> | |
</div> | |
</li> | |
<li id="Reason"> | |
<label class="description" for="Reason">Reason you would like to be | |
contacted</label> | |
<div> | |
<textarea class="element textarea medium" id="Reason" name= | |
"Reason"></textarea> | |
</div> | |
</li> | |
<li id="agree"><label class="description" for="agree">I agree to the terms in | |
the disclaimer</label> <span><input class="element checkbox" id="agree" name= | |
"agree" type="checkbox" value="1"></span></li> | |
<li class="buttons"> | |
<input name="form_id" type="hidden" value="1133213"> | |
<div class="g-recaptcha" data-sitekey= | |
"6LfwgSATAAAAANB824fo1raRkY47Sh8pX-GWlNK9"></div><input class="button_text" | |
id="saveForm" name="submit" type="submit" value="Submit"> | |
</li> | |
</ul> | |
</form><?php } ?><!-- /Contact --> |
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<?php | |
$EmailFrom = "[email protected]"; | |
$EmailTo = "[email protected]"; | |
$Subject = "Contact form"; | |
$Name = Trim(stripslashes($_POST['Name'])); | |
$Company = Trim(stripslashes($_POST['Company'])); | |
$Email = Trim(stripslashes($_POST['Email'])); | |
$Phone = Trim(stripslashes($_POST['Phone'])); | |
$City = Trim(stripslashes($_POST['City'])); | |
$State = Trim(stripslashes($_POST['State'])); | |
$Zip = Trim(stripslashes($_POST['Zip'])); | |
$How = Trim(stripslashes($_POST['How'])); | |
$contacted = Trim(stripslashes($_POST['contacted'])); | |
$Reason = Trim(stripslashes($_POST['Reason'])); | |
$agree = Trim(stripslashes($_POST['agree'])); | |
// validation | |
$validationOK=true; | |
if (!$validationOK) { | |
print "<meta http-equiv=\"refresh\" content=\"0;URL=error.htm\">"; | |
exit; | |
} | |
// prepare email body text | |
$Body = ""; | |
$Body .= "Name: "; | |
$Body .= $Name; | |
$Body .= "\n"; | |
$Body .= "Company: "; | |
$Body .= $Company; | |
$Body .= "\n"; | |
$Body .= "Email: "; | |
$Body .= $Email; | |
$Body .= "\n"; | |
$Body .= "Phone: "; | |
$Body .= $Phone; | |
$Body .= "\n"; | |
$Body .= "City: "; | |
$Body .= $City; | |
$Body .= "\n"; | |
$Body .= "Zip: "; | |
$Body .= $Zip; | |
$Body .= "\n"; | |
$Body .= "How: "; | |
$Body .= $How; | |
$Body .= "\n"; | |
$Body .= "contacted: "; | |
$Body .= $contacted; | |
$Body .= "\n"; | |
$Body .= "Reason: "; | |
$Body .= $Reason; | |
$Body .= "\n"; | |
$Body .= "agree: "; | |
$Body .= $agree; | |
$Body .= "\n"; | |
// send email | |
$success = mail($EmailTo, $Subject, $Body, "From: <$EmailFrom>"); | |
// redirect to success page | |
if ($success){ | |
print "<meta http-equiv=\"refresh\" content=\"0;URL=contactthanks.php\">"; | |
} | |
else{ | |
print "<meta http-equiv=\"refresh\" content=\"0;URL=error.htm\">"; | |
} | |
?> |
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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Strict//EN"> | |
<head> | |
<title>Thank you</title> | |
<link rel="stylesheet" type="text/css" href="style.css" /> | |
</head> | |
<body> | |
<div id="page-wrap"> | |
<h1>Your message has been sent!</h1><br /> | |
<p><a href="index.php">Back to Contact Form</a></p> | |
</div> | |
</body> | |
</html> |
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