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<?
require_once "formvalidator.php";
require_once "php/mailgun.php";
if(!empty($_POST))
{
$validator = new FormValidator();
$validator->addValidation("anm","req","<a onclick=\"redborder('anm');\" href='#personal'>Association Name</a> :");
$validator->addValidation("con","req","<a onclick=\"redborder('con');\" href='#personal'>Contact Name</a> :");
$validator->addValidation("add","req","<a onclick=\"redborder('add');\" href='#personal'>Address</a> :");
$validator->addValidation("cit","req","<a onclick=\"redborder('cit');\" href='#personal'>City</a> :");
$validator->addValidation("sta","req","<a onclick=\"redborder('sta');\" href='#personal'>State</a> :");
$validator->addValidation("zip","req","<a onclick=\"redborder('zip');\" href='#personal'>Zip</a> :");
$validator->addValidation("ph3","req","<a onclick=\"redborder('phn');\" href='#personal'>Valid Phone</a> :");
$validator->addValidation("eml","email","<a onclick=\"redborder('eml');\" href='#personal'>Please enter a valid email</a> :");
$validator->addValidation("eml","req","<a onclick=\"redborder('eml');\" href='#personal'>Valid Email Address</a> :");
$validator->addValidation("met","req","<a onclick=\"redborder('met');\" href='#meeting'>Type of Meeting</a> :");
$validator->addValidation("num","req","<a onclick=\"redborder('num');\" href='#meeting'># of Attendees</a> :");
$validator->addValidation("loc","req","<a onclick=\"redborder('loc');\" href='#meeting'>Meeting Location</a> :");
$validator->addValidation("dmn","req","<a onclick=\"redborder('dmn');\" href='#meeting'>Meeting Month</a> :");
$validator->addValidation("ddy","req","<a onclick=\"redborder('ddy');\" href='#meeting'>Meeting Day</a> :");
$validator->addValidation("dyr","req","<a onclick=\"redborder('dyr');\" href='#meeting'>Meeting Year</a> :");
$validator->addValidation("lor","req","<a onclick=\"redborder('lor');\" href='#attendee'>Attendee Low Estimate</a> :");
$validator->addValidation("avr","req","<a onclick=\"redborder('avr');\" href='#attendee'>Attendee Average Estimate</a> :");
$validator->addValidation("hir","req","<a onclick=\"redborder('hir');\" href='#attendee'>Attendee High Estimate</a> :");
$validator->addValidation("per","req","<a onclick=\"redborder('per');\" href='#attendee'>Attendee Type</a> :");
$validator->addValidation("pln","req","<a onclick=\"redborder('pln');\" href='#sessions'>Planning Sessions</a> :");
$validator->addValidation("val","req","<a onclick=\"redborder('val');\" href='#validate'>Validation Code</a>");
if($validator->ValidateForm())
{
//$to = "etoddt@gmail.com";
$to = "heinz@americansocietyap.org, cameron@assetspeaker.com, hans@assetspeaker.com, tracy@assetspeaker.com";
$subject = "Improved Patient Care Speaker Request Form";
$from = "requestspeaker@assetspeaker.com";
$headers = "From: $from\r\nReplyTo: $from";
$anm = $_POST['anm'];
$con = $_POST['con'];
$ttl = $_POST['ttl'];
$add = $_POST['add'];
$cit = $_POST['cit'];
$sta = $_POST['sta'];
$zip = $_POST['zip'];
$ph1 = $_POST['ph1'];
$ph2 = $_POST['ph2'];
$ph3 = $_POST['ph3'];
$fx1 = $_POST['fx1'];
$fx2 = $_POST['fx2'];
$fx3 = $_POST['fx3'];
$eml = $_POST['eml'];
$sit = $_POST['sit'];
$met = $_POST['met'];
$num = $_POST['num'];
$loc = $_POST['loc'];
$dmn = $_POST['dmn'];
$ddy = $_POST['ddy'];
$dyr = $_POST['dyr'];
$tim = $_POST['tim'];
$lor = $_POST['lor'];
$avr = $_POST['avr'];
$hir = $_POST['hir'];
$per = $_POST['per'];
$key = $_POST['key'];
$gen = $_POST['gen'];
$bre = $_POST['bre'];
$brn = $_POST['brn'];
$pln = $_POST['pln'];
$brk = $_POST['brk'];
$mrn = $_POST['mrn'];
$two = $_POST['two'];
$oth = $_POST['oth'];
$dat = date("F j, Y, g:i A");
$body ="
Speaker Request Form
CONTACT INFORMATION
___________________
Association Name: $anm
Contact Name: $ttl $con
Address:$add
$cit, $sta $zip
Phone: ($ph1) $ph2-$ph3
Fax: ($fx1) $fx2-$fx3
E-Mail: $eml
Website: $sit
MEETING INFORMATION
___________________
Number of Attendees: $num
Meeting Type: $met
Meeting Location: $loc
Meeting Date: $dmn $ddy, $dyr
Meeting Time: $tim
How many attend your meetings?
Attendance:
low-$lor
average-$avr
high-$hir
Types of Attendees:
$per
Type of Speaking Engagement:
Keynote - $key
General - $gen
Breakout - $bre, $brn
Would you consider having a break for Q&A after our presentation?
$brk
Are you capable of accomodating a morning session?
$mrn
Are you capable of accomodating a two-hour session?
$two
Other Comments:
$oth";
//if(mail($to, $subject, $body, $headers)){
mailgun_send_message($to,$from,$subject,nl2br($body),1,'ImprovedPatientCare Schedule','','','',0,array(),'',0);
$output = '<div class="success"><p><b>EMAIL SENT:</b> Please allow 24-48 hours for a representative to contact you regarding your inquiry.</p></div>';
$reset = 'reset';
//}
} else {
$output = "<div class='error'>";
$output .= "<p><font style='font-weight:bold;color:#CC0000'>ERROR - PLEASE ENTER:</font><br />";
$error_hash = $validator->GetErrors();
foreach($error_hash as $inpname => $inp_err)
{
$output .= "<u>$inp_err</u> ";
}
$output .= "</p><span class='message'>^ Click on the Links Above to Find the Required Form ^</span></div>";
}
}
$body_id = 'schedul';
$title = 'Schedule a Speaker';
require_once('header.php'); ?>
<script>
<!--
function checkRadio() {
if (document.dform.bre.checked == true) {
document.getElementById('breakout').style.display = 'block';
} else {
document.getElementById('breakout').style.display = 'none';
}
}
function clearSchedule() {
document.dform.anm.value = '';
document.dform.add.value = '';
document.dform.cit.value = '';
document.getElementById('sta').value = '';
document.dform.zip.value = '';
document.dform.con.value = '';
document.dform.ttl.value = '';
document.dform.ph1.value = '';
document.dform.ph2.value = '';
document.dform.ph3.value = '';
document.dform.fx1.value = '';
document.dform.fx2.value = '';
document.dform.fx3.value = '';
document.dform.eml.value = '';
document.dform.sit.value = '';
document.getElementById('met').value = '';
document.dform.num.value = '';
document.dform.loc.value = '';
document.getElementById('dmn').value = '';
document.getElementById('ddy').value = '';
document.dform.dyr.value = '';
document.dform.tim.value = '';
document.dform.lor.value = '';
document.dform.avr.value = '';
document.dform.hir.value = '';
document.dform.per.value = '';
document.dform.key.checked = false;
document.dform.gen.checked = false;
document.dform.bre.checked = false;
document.dform.brn.value = '';
document.dform.pln.value = '';
document.dform.brk[0].checked = false;
document.dform.brk[1].checked = false;
document.dform.mrn[0].checked = false;
document.dform.mrn[1].checked = false;
document.dform.two[0].checked = false;
document.dform.two[1].checked = false;
document.dform.oth.value = '';
document.dform.val.value = '';
}
function clearborder() {
document.dform.anm.className='txt';
document.dform.con.className='txt';
document.dform.add.className='add';
document.dform.cit.className='txt';
document.dform.sta.className='';
document.dform.zip.className='txt';
document.getElementById('phn').className='';
document.dform.eml.className='txt';
document.dform.met.className='';
document.dform.num.className='sml';
document.dform.loc.className='';
document.dform.dmn.className='';
document.dform.ddy.className='';
document.dform.dyr.className='sml';
document.dform.lor.className='sml';
document.dform.avr.className='sml';
document.dform.hir.className='sml';
document.dform.per.className='';
document.dform.pln.className='';
document.dform.val.className='';
}
function redborder(id) {
clearborder();
document.getElementById(id).className+=' red';
}
-->
</script>
<?php echo $output;?>
<form name="dform" id="dform" method="post" action="<?= $_SERVER['PHP_SELF']; ?>" accept-charset="UTF-8">
<input type="hidden" id="check" value="<?php print $reset?>" onclick="javscript:return clearSchedule();" />
<a name="personal"></a><br /><br />
<h2>Contact Information</h2>
<table cellpadding="0" cellspacing="0" border="0" class="request">
<tr>
<td>
<table cellspacing="3" class="half">
<tr>
<td class="right">Assocation<br />Name:</td>
<td><input id="anm" name="anm" type="text" class="txt" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valName('dform','anm');" value="<?php if (isset($_POST['anm'])){echo htmlspecialchars($_POST['anm'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td class="right">Address:</td>
<td><textarea id="add" name="add" class="add" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'"><?php if (isset($_POST['add'])){echo htmlspecialchars($_POST['add'], ENT_QUOTES);}?></textarea></td>
</tr>
<tr>
<td class="right">City:</td>
<td><input id="cit" name="cit" type="text" class="txt" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valName('dform','cit');" value="<?php if (isset($_POST['cit'])){echo htmlspecialchars($_POST['cit'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td class="right">State:</td>
<td><select id="sta" name="sta"
onChange="if (dform.sub[dform.sub.selectedIndex].value === '') {alert('Please choose an option.'); return false;};"
onfocus="this.style.color='#566c92'" onblur="this.style.color='#11243a'">
<option value="">--please select--</option>
<option></option>
<option value="AL" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'AL') {echo 'selected="selected"';} ?>>AL</option>
<option value="AK" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'AK') {echo 'selected="selected"';} ?>>AK</option>
<option value="AZ" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'AZ') {echo 'selected="selected"';} ?>>AZ</option>
<option value="AR" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'AR') {echo 'selected="selected"';} ?>>AR</option>
<option value="CA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'CA') {echo 'selected="selected"';} ?>>CA</option>
<option value="CO" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'CO') {echo 'selected="selected"';} ?>>CO</option>
<option value="CT" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'CT') {echo 'selected="selected"';} ?>>CT</option>
<option value="DE" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'DE') {echo 'selected="selected"';} ?>>DE</option>
<option value="DC" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'DE') {echo 'selected="selected"';} ?>>DC</option>
<option value="FL" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'FL') {echo 'selected="selected"';} ?>>FL</option>
<option value="GA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'GA') {echo 'selected="selected"';} ?>>GA</option>
<option value="HI" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'HI') {echo 'selected="selected"';} ?>>HI</option>
<option value="ID" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'ID') {echo 'selected="selected"';} ?>>ID</option>
<option value="IL" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'IL') {echo 'selected="selected"';} ?>>IL</option>
<option value="IN" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'IN') {echo 'selected="selected"';} ?>>IN</option>
<option value="IA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'IA') {echo 'selected="selected"';} ?>>IA</option>
<option value="KS" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'KS') {echo 'selected="selected"';} ?>>KS</option>
<option value="KY" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'KY') {echo 'selected="selected"';} ?>>KY</option>
<option value="LA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'LA') {echo 'selected="selected"';} ?>>LA</option>
<option value="ME" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'ME') {echo 'selected="selected"';} ?>>ME</option>
<option value="MD" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'MD') {echo 'selected="selected"';} ?>>MD</option>
<option value="MA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'MA') {echo 'selected="selected"';} ?>>MA</option>
<option value="MI" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'MI') {echo 'selected="selected"';} ?>>MI</option>
<option value="MN" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'MN') {echo 'selected="selected"';} ?>>MN</option>
<option value="MS" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'MS') {echo 'selected="selected"';} ?>>MS</option>
<option value="MO" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'MO') {echo 'selected="selected"';} ?>>MO</option>
<option value="MT" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'MT') {echo 'selected="selected"';} ?>>MT</option>
<option value="NE" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'NE') {echo 'selected="selected"';} ?>>NE</option>
<option value="NV" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'NV') {echo 'selected="selected"';} ?>>NV</option>
<option value="NH" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'NH') {echo 'selected="selected"';} ?>>NH</option>
<option value="NJ" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'NJ') {echo 'selected="selected"';} ?>>NJ</option>
<option value="NM" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'NM') {echo 'selected="selected"';} ?>>NM</option>
<option value="NY" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'NY') {echo 'selected="selected"';} ?>>NY</option>
<option value="NC" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'NC') {echo 'selected="selected"';} ?>>NC</option>
<option value="ND" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'ND') {echo 'selected="selected"';} ?>>ND</option>
<option value="OH" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'OH') {echo 'selected="selected"';} ?>>OH</option>
<option value="OK" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'OK') {echo 'selected="selected"';} ?>>OK</option>
<option value="OR" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'OR') {echo 'selected="selected"';} ?>>OR</option>
<option value="PA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'PA') {echo 'selected="selected"';} ?>>PA</option>
<option value="RI" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'RI') {echo 'selected="selected"';} ?>>RI</option>
<option value="SC" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'SC') {echo 'selected="selected"';} ?>>SC</option>
<option value="SD" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'SD') {echo 'selected="selected"';} ?>>SD</option>
<option value="TN" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'TN') {echo 'selected="selected"';} ?>>TN</option>
<option value="TX" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'TX') {echo 'selected="selected"';} ?>>TX</option>
<option value="UT" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'UT') {echo 'selected="selected"';} ?>>UT</option>
<option value="VT" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'VT') {echo 'selected="selected"';} ?>>VT</option>
<option value="VA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'VA') {echo 'selected="selected"';} ?>>VA</option>
<option value="WA" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'WA') {echo 'selected="selected"';} ?>>WA</option>
<option value="WV" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'WV') {echo 'selected="selected"';} ?>>WV</option>
<option value="WI" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'WI') {echo 'selected="selected"';} ?>>WI</option>
<option value="WY" <?php if (isset($_POST['sta']) && $_POST['sta'] == 'WY') {echo 'selected="selected"';} ?>>WY</option>
</select></td>
</tr>
<tr>
<td class="right">Zip:</td>
<td><input id="zip" name="zip" type="text" maxlength="5" class="txt" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valNum(this);" value="<?php if (isset($_POST['zip'])){echo htmlspecialchars($_POST['zip'], ENT_QUOTES);}?>" /></td>
</tr>
</table>
<table cellspacing="3" class="half">
<tr>
<td class="right">Contact Name:</td>
<td><input id="con" name="con" type="text" class="txt" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valName('dform','con');" value="<?php if (isset($_POST['con'])){echo htmlspecialchars($_POST['con'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td class="right">Contact Title:</td>
<td><input name="ttl" type="text" class="txt" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" value="<?php if (isset($_POST['ttl'])){echo htmlspecialchars($_POST['ttl'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td class="right">Phone #:</td>
<td id="phn"><input id="ph1" name="ph1" maxlength="3" type="text" class="phn" onKeyDown="TabNext(this,'down',3)"
onKeyUp="TabNext(this,'up',3,this.form.ph2);valNum(this)" onblur="this.style.color='#11243a'"
value="<?php if (isset($_POST['ph1'])){echo htmlspecialchars($_POST['ph1'], ENT_QUOTES);}?>" />
<input id="ph2" name="ph2" maxlength="3" type="text" class="phn" onKeyDown="TabNext(this,'down',3)"
onKeyUp="TabNext(this,'up',3,this.form.ph3);valNum(this)" onblur="this.style.color='#11243a'"
value="<?php if (isset($_POST['ph2'])){echo htmlspecialchars($_POST['ph2'], ENT_QUOTES);}?>" />
<input id="ph3" name="ph3" maxlength="4" type="text" class="phn2" onKeyUp="valNum(this)" onblur="this.style.color='#11243a'"
value="<?php if (isset($_POST['ph3'])){echo htmlspecialchars($_POST['ph3'], ENT_QUOTES);}?>" />
</td>
</tr>
<tr>
<td class="right">Fax #:</td>
<td><input name="fx1" maxlength="3" type="text" class="phn" onKeyDown="TabNext(this,'down',3)"
onKeyUp="TabNext(this,'up',3,this.form.fx2);valNum(this)" onblur="this.style.color='#11243a'"
value="<?php if (isset($_POST['fx1'])){echo htmlspecialchars($_POST['fx1'], ENT_QUOTES);}?>" />
<input name="fx2" maxlength="3" type="text" class="phn" onKeyDown="TabNext(this,'down',3)"
onKeyUp="TabNext(this,'up',3,this.form.fx3);valNum(this)" onblur="this.style.color='#11243a'"
value="<?php if (isset($_POST['fx2'])){echo htmlspecialchars($_POST['fx2'], ENT_QUOTES);}?>" />
<input name="fx3" maxlength="4" type="text"a class="phn2" onKeyUp="valNum(this)" onblur="this.style.color='#11243a'"
value="<?php if (isset($_POST['fx3'])){echo htmlspecialchars($_POST['fx3'], ENT_QUOTES);}?>" />
</td>
</tr>
<tr>
<td class="right">Email Address:</td>
<td><input id="eml" name="eml" type="text" class="txt" onfocus="this.style.color='#0073cc'" onblur="javascript:return valEmail('dform','eml')" value="<?php if (isset($_POST['eml'])){echo htmlspecialchars($_POST['eml'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td class="right">Web Site:</td>
<td><input id="sit" name="sit" type="text" class="txt" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" value="<?php if (isset($_POST['sit'])){echo htmlspecialchars($_POST['sit'], ENT_QUOTES);}?>" /></td>
</tr>
</table>
</td>
</tr>
</table>
<a name="meeting"></a>
<h2>Meeting Information</h2>
<table cellpadding="0" cellspacing="0" border="0" class="request">
<tr>
<td>
<table cellspacing="3" class="half">
<tr>
<td class="right">Meeting type:</td>
<td><select id="met" name="met"
onChange="if (dform.met[dform.met.selectedIndex].value === '') {alert('Please choose an option.'); return false;};"
onfocus="this.style.color='#566c92'" onblur="this.style.color='#11243a'">
<option value="">--please select--</option>
<option></option>
<option value="met_type1" <?php if (isset($_POST['met']) && $_POST['met'] == 'met_type1') {echo 'selected="selected"';} ?>>Speaking Engagement</option>
<option value="met_type2" <?php if (isset($_POST['met']) && $_POST['met'] == 'met_type2') {echo 'selected="selected"';} ?>>Video Conference</option>
<option value="met_type3" <?php if (isset($_POST['met']) && $_POST['met'] == 'met_type3') {echo 'selected="selected"';} ?>>Consulting/Training</option>
</select></td>
</tr>
</table>
<table cellspacing="3" class="half">
<tr>
<td width="40%" class="right"># of Attendees:</td>
<td><input id="num" name="num" maxlength="5" type="text" class="sml" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valNum(this);" value="<?php if (isset($_POST['num'])){echo htmlspecialchars($_POST['num'], ENT_QUOTES);}?>" /></td>
</tr>
</table>
<table cellspacing="3" class="full">
<tr>
<td>Meeting Location:</td>
</tr>
<tr>
<td><textarea id="loc" name="loc" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'"><?php if (isset($_POST['loc'])){echo htmlspecialchars($_POST['loc'], ENT_QUOTES);}?></textarea></td>
</tr>
</table>
<table cellspacing="3" class="half">
<tr>
<td>Meeting Date:</td>
<td><select id="dmn" name="dmn" style="width:60px"
onChange="if (dform.dmn[dform.dmn.selectedIndex].value === '') {alert('Please choose an option.'); return false;};"
onfocus="this.style.color='#566c92'" onblur="this.style.color='#11243a'">
<option value=""></option>
<option value="JAN" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'JAN') {echo 'selected="selected"';} ?>>JAN</option>
<option value="FEB" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'FEB') {echo 'selected="selected"';} ?>>FEB</option>
<option value="MAR" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'MAR') {echo 'selected="selected"';} ?>>MAR</option>
<option value="APR" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'APR') {echo 'selected="selected"';} ?>>APR</option>
<option value="MAY" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'MAY') {echo 'selected="selected"';} ?>>MAY</option>
<option value="JUN" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'JUN') {echo 'selected="selected"';} ?>>JUN</option>
<option value="JUL" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'JUL') {echo 'selected="selected"';} ?>>JUL</option>
<option value="AUG" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'AUG') {echo 'selected="selected"';} ?>>AUG</option>
<option value="SEP" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'SEP') {echo 'selected="selected"';} ?>>SEP</option>
<option value="OCT" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'OCT') {echo 'selected="selected"';} ?>>OCT</option>
<option value="NOV" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'NOV') {echo 'selected="selected"';} ?>>NOV</option>
<option value="DEC" <?php if (isset($_POST['dmn']) && $_POST['dmn'] == 'DEC') {echo 'selected="selected"';} ?>>DEC</option>
</select>
<!--script>DateInput('orderdate', true, 'DD-MON-YYYY')</script-->
</td>
<td><select id="ddy" name="ddy" style="width:50px"
onChange="if (dform.ddy[dform.ddy.selectedIndex].value === '') {alert('Please choose an option.'); return false;};"
onfocus="this.style.color='#566c92'" onblur="this.style.color='#11243a'">
<option value=""></option>
<option value="1" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '1') {echo 'selected="selected"';} ?>>1</option>
<option value="2" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '2') {echo 'selected="selected"';} ?>>2</option>
<option value="3" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '3') {echo 'selected="selected"';} ?>>3</option>
<option value="4" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '4') {echo 'selected="selected"';} ?>>4</option>
<option value="5" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '5') {echo 'selected="selected"';} ?>>5</option>
<option value="6" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '6') {echo 'selected="selected"';} ?>>6</option>
<option value="7" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '7') {echo 'selected="selected"';} ?>>7</option>
<option value="8" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '8') {echo 'selected="selected"';} ?>>8</option>
<option value="9" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '9') {echo 'selected="selected"';} ?>>9</option>
<option value="10" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '10') {echo 'selected="selected"';} ?>>10</option>
<option value="11" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '11') {echo 'selected="selected"';} ?>>11</option>
<option value="12" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '12') {echo 'selected="selected"';} ?>>12</option>
<option value="13" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '13') {echo 'selected="selected"';} ?>>13</option>
<option value="14" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '14') {echo 'selected="selected"';} ?>>14</option>
<option value="15" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '15') {echo 'selected="selected"';} ?>>15</option>
<option value="16" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '16') {echo 'selected="selected"';} ?>>16</option>
<option value="17" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '17') {echo 'selected="selected"';} ?>>17</option>
<option value="18" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '18') {echo 'selected="selected"';} ?>>18</option>
<option value="19" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '19') {echo 'selected="selected"';} ?>>19</option>
<option value="20" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '20') {echo 'selected="selected"';} ?>>20</option>
<option value="21" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '21') {echo 'selected="selected"';} ?>>21</option>
<option value="22" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '22') {echo 'selected="selected"';} ?>>22</option>
<option value="23" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '23') {echo 'selected="selected"';} ?>>23</option>
<option value="24" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '24') {echo 'selected="selected"';} ?>>24</option>
<option value="25" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '25') {echo 'selected="selected"';} ?>>25</option>
<option value="26" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '26') {echo 'selected="selected"';} ?>>26</option>
<option value="27" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '27') {echo 'selected="selected"';} ?>>27</option>
<option value="28" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '28') {echo 'selected="selected"';} ?>>28</option>
<option value="29" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '29') {echo 'selected="selected"';} ?>>29</option>
<option value="30" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '30') {echo 'selected="selected"';} ?>>30</option>
<option value="31" <?php if (isset($_POST['ddy']) && $_POST['ddy'] == '31') {echo 'selected="selected"';} ?>>31</option>
</select>
<!--script>DateInput('orderdate', true, 'DD-MON-YYYY')</script-->
</td>
<td><input id="dyr" name="dyr" type="text" maxlength="4" class="sml" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valNum(this);" value="<?php if (isset($_POST['dyr'])){echo htmlspecialchars($_POST['dyr'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td></td>
<td valign="top" style="color:#666">Month</td>
<td valign="top" style="color:#666">Day</td>
<td valign="top" style="color:#666">Year</td>
</tr>
</table>
<table cellspacing="3" class="half">
<tr>
<td class="right">Apprx. Times:</td>
<td><input name="tim" type="text" class="txt" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" value="<?php if (isset($_POST['tim'])){echo htmlspecialchars($_POST['tim'], ENT_QUOTES);}?>" /></td>
</tr>
</table>
</td>
</tr>
</table>
<a name="attendee"></a>
<table cellpadding="6" cellspacing="0" border="0" class="request">
<tr>
<td valign="top">
<table cellspacing="3" class="full">
<tr>
<td colspan="6">How many attend your meetings?</td>
</tr>
<tr>
<td class="right">Low #:</td>
<td><input id="lor" class="sml" name="lor" maxlength="5" type="text" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valNum(this);" value="<?php if (isset($_POST['lor'])){echo htmlspecialchars($_POST['lor'], ENT_QUOTES);}?>" /></td>
<td class="right">Average #:</td>
<td><input id="avr" class="sml" name="avr" maxlength="5" type="text" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valNum(this);" value="<?php if (isset($_POST['avr'])){echo htmlspecialchars($_POST['avr'], ENT_QUOTES);}?>" /></td>
<td class="right">High #:</td>
<td><input id="hir" class="sml" name="hir" maxlength="5" type="text" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onKeyUp="javascript:return valNum(this);" value="<?php if (isset($_POST['hir'])){echo htmlspecialchars($_POST['hir'], ENT_QUOTES);}?>" /></td>
</tr>
<tr>
<td colspan="6">Who attends and approximate % of each group?</td>
</tr>
<tr>
<td colspan="6"><textarea id="per" name="per" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'"><?php if (isset($_POST['per'])){echo htmlspecialchars($_POST['per'], ENT_QUOTES);}?></textarea></td>
</tr>
</table>
</td>
</tr>
</table>
<a name="sessions"></a>
<table cellpadding="2" cellspacing="0" border="0" class="request">
<tr>
<td valign="top">
<table cellspacing="3" class="full">
<tr>
<td colspan="4">What type of session are you considering us for?</td>
</tr>
<tr>
<td><label><input name="key" type="checkbox" value="YES!" class="check" <?php if (isset($_POST['key'])) {echo 'checked="checked"';}?> />Keynote</label></td>
<td><label><input name="gen" type="checkbox" value="YES!" class="check" <?php if (isset($_POST['gen'])) {echo 'checked="checked"';}?> />General</label></td>
<td><label for="bre" onclick="if (document.getElementById('bre').checked == true) {
document.getElementById('breakout').style.display = 'block';
} else {
document.getElementById('breakout').style.display = 'none';
}">
<input id="bre" name="bre" type="checkbox" value="YES! -" class="check"
<?php if (isset($_POST['bre'])) {echo 'checked="checked"';}?> />Breakout</label>
</td>
<td width="40%"></td>
</tr>
</table>
<table cellspacing="3" class="full">
<tr id="breakout" style="display:none">
<td colspan="4">
<table>
<tr>
<td style="white-space:nowrap">If Breakout, # of concurent sessions:</td>
<td><input name="brn" type="text" maxlength="2" class="zip" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'" onkeyup="javascript:return valNum(this);" value="<?php if (isset($_POST['brn'])){echo htmlspecialchars($_POST['brn'], ENT_QUOTES);}?>" /></td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="4">When do you meet to plan your meetings/conferences?</td>
</tr>
<tr>
<td colspan="4"><textarea id="pln" name="pln" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'"><?php if (isset($_POST['pln'])){echo htmlspecialchars($_POST['pln'], ENT_QUOTES);}?></textarea></td>
</tr>
</table>
</td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" border="0" class="request">
<tr>
<td valign="top">
<table cellpadding="6" class="full">
<tr>
<td colspan="3">Would you consider having a break for Q&A after our presentation?</td>
</tr>
<tr>
<td><label><input type="radio" name="brk" value="YES!" <?php if (isset($_POST['brk']) && $_POST['brk'] == 'YES!') {echo 'checked="checked"';} ?> /> Yes</label></td>
<td><label><input type="radio" name="brk" value="No" <?php if (isset($_POST['brk']) && $_POST['brk'] == 'No') {echo 'checked="checked"';} ?> /> No</label></td>
<td width="50%"></td>
</tr>
<tr>
<td colspan="3">Are you capable of accomodating a morning session?</td>
</tr>
<tr>
<td><label><input type="radio" name="mrn" value="YES!" <?php if (isset($_POST['mrn']) && $_POST['mrn'] == 'YES!') {echo 'checked="checked"';} ?> /> Yes</label></td>
<td><label><input type="radio" name="mrn" value="No" <?php if (isset($_POST['mrn']) && $_POST['mrn'] == 'No') {echo 'checked="checked"';} ?> /> No</label></td>
<td width="50%"></td>
</tr>
<tr>
<td colspan="3">Are you capable of accomodating a two-hour session?</td>
</tr>
<tr>
<td><label><input type="radio" name="two" value="YES!" <?php if (isset($_POST['two']) && $_POST['two'] == 'YES!') {echo 'checked="checked"';} ?> /> Yes</label></td>
<td><label><input type="radio" name="two" value="No" <?php if (isset($_POST['two']) && $_POST['two'] == 'No') {echo 'checked="checked"';} ?> /> No</label></td>
<td width="50%"></td>
</tr>
</table>
</td>
</tr>
</table>
<table cellpadding="0" cellspacing="0" border="0" class="request">
<tr>
<td valign="top">
<table cellpadding="6" class="full">
<tr>
<td>Other information you would like us to know about your organization?</td>
</tr>
<tr>
<td><textarea name="oth" onfocus="this.style.color='#0073cc'" onblur="this.style.color='#11243a'"><?php if (isset($_POST['oth'])){echo htmlspecialchars($_POST['oth'], ENT_QUOTES);}?></textarea></td>
</tr>
</table>
</td>
</tr>
</table>
<a name="validate"></a>
<table cellpadding="0" cellspacing="0" border="0" class="request" style="background-color:#f0eae1; border-bottom:1px dotted #555555">
<tr>
<td valign="top">
<table cellpadding="6" class="full">
<tr>
<td colspan="2"><strong>Security Question</strong> - Please Type the Letters at Right</td>
<td align="right"><img src="images/test.jpg" style="float:left; margin:0 5px 0 20px; padding:0" /></td>
<td>=</td>
<td align="left">
<input name="val" id="val" type="text" class="zip" maxlength="4" style="border-width:1px; border-style:solid; border-color:black; float:left"
onfocus="this.style.color='#0073cc'"
onblur="this.style.color='#11243a';
if (document.getElementById('val').value === 'AJ3z') {
document.getElementById('val').style.borderColor = 'green';
document.getElementById('val').style.borderWidth = '2px';
} else if (document.getElementById('val').value === '') {
document.getElementById('val').style.borderColor = 'black';
document.getElementById('val').style.borderWidth = '1px';
} else {
document.getElementById('val').style.borderColor = 'red';
document.getElementById('val').style.borderWidth = '2px';
document.getElementById('val').value = '';
alert('The Value is Incorrect - Please Try Again');
}" />
</td>
</tr>
</table>
</td>
</tr>
</table>
<center><input type="submit" name="schedule" class="submit" value="Schedule Speaker" onmouseover="this.style.backgroundPosition='top center'" onmouseout="this.style.backgroundPosition='bottom center'" /></center>
</form>
<script type="text/javascript" language="javascript">
<!--
onload = function() {
if(document.getElementById('check').value != '') {
setTimeout('clearSchedule()', 200);
setTimeout('checkRadio()', 300);
} else {
setTimeout('checkRadio()', 300);
}
}
-->
</script>
<? require_once('footer.php'); ?>