here is the full script
<?php
// $link = mysql_connect("localhost", "user", "password") or die("Error: Could not connect");
// mysql_select_db("db") or die("Error:Could not select database");
if ($submit == "Send")
{
$zaction = "send";
} else {
$zaction = "form";
}
?>
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
<head>
<meta http-equiv="content-type" content="text/html;charset=iso-8859-1">
<meta name="generator" content="Adobe GoLive 6">
<title>Fagen Pharmacy Promo Request Form</title>
<SCRIPT>
function handleEnter (field, event) {
var keyCode = event.keyCode ? event.keyCode :
event.which ? event.which : event.charCode;
if (keyCode == 13) {
var i;
for (i = 0; i < 45; i++)
if (field == field.form.elements)
break;
i = (i + 1) % field.form.elements.length;
field.form.elements.focus();
return false;
}
else
return true;
}
</SCRIPT>
</head>
<body bgcolor="#ffffff">
<div align="center">
<p><img src="/images1/fagen_to_jpeg.gif" alt="" width="406" height="179" border="0"><br>
<img src="/images1/line.jpg" alt="" width="500" height="3" border="0"><br>
<font size="5" color="#d60021" face="Arial"><u>Promo Request Form</u></font><font color="#d60021"><br>
</font><img src="../images_admin/line.jpg" alt="" width="500" height="3" border="0"><br>
<img src="/images1/line.jpg" alt="" width="500" height="3" border="0"><br>
<br>
<?
if ($zaction=='form')
{ ?><font color="#d60021" face="Arial" size="5">New Entry</font>
<?
form();
}
if ($zaction=='send')
{
send($_POST);
echo "<h1>Message Sent</h1>\n\n";
}
?><br>
<img src="/images1/line.jpg" alt="" width="500" height="3" border="0"><br>
<table width="479" border="0" cellspacing="0" cellpadding="0" cool gridx="16" gridy="16" height="31" showgridx showgridy usegridx usegridy>
<tr height="30">
<td width="320" height="30" valign="top" align="left" xpos="0"><a href="/index1.html"><img src="images1/mainmenu.gif" alt="" width="155" height="30" border="0"></a></td>
<td width="158" height="30" valign="top" align="left" xpos="320"><a href="/admin"><img src="images1/adminmenu.gif" alt="" width="155" height="30" border="0"></a></td>
<td width="1" height="30"><spacer type="block" width="1" height="30"></td>
</tr>
<tr height="1" cntrlrow>
<td width="320" height="1"><spacer type="block" width="320" height="1"></td>
<td width="158" height="1"><spacer type="block" width="158" height="1"></td>
<td width="1" height="1"></td>
</tr>
</table>
<br>
All information contained within is propriatory and may not be transmited, duplicated,<br>
or shown without prior written consent from Fagen Pharmacy.</div>
</body>
</html>
<?
function send($POST)
{
$to="promos@fagenpharmacy.com";
$from="promos@fagenpharmacy.com";
$promo=$POST['promo'];
$subject="Promo Request ".$POST['promo'];
$include=$POST['include'];
$startdate=$POST['startdate'];
$enddate=$POST['enddate'];
$upccode=$POST['upccode'];
$vendor=$POST['vendor'];
$price=$POST['price'];
$saleprice2=$POST['saleprice2'];
$upccode2=$POST['upccode2'];
$vendor2=$POST['vendor2'];
$price2=$POST['price2'];
$saleprice2=$POST['saleprice2'];
$upccode3=$POST['upccode3'];
$vendor3=$POST['vendor3'];
$price3=$POST['price3'];
$saleprice3=$POST['saleprice3'];
$upccode4=$POST['upccode4'];
$vendor4=$POST['vendor4'];
$price4=$POST['price4'];
$saleprice4=$POST['saleprice4'];
$upccode5=$POST['upccode5'];
$vendor5=$POST['vendor5'];
$price5=$POST['price5'];
$saleprice5=$POST['saleprice5'];
$upccode6=$POST['upccode6'];
$vendor6=$POST['vendor6'];
$price6=$POST['price6'];
$saleprice6=$POST['saleprice6'];
$upccode7=$POST['upccode7'];
$vendor7=$POST['vendor7'];
$price7=$POST['price7'];
$saleprice7=$POST['saleprice7'];
$upccode8=$POST['upccode8'];
$vendor8=$POST['vendor8'];
$price8=$POST['price8'];
$saleprice8=$POST['saleprice8'];
$upccode9=$POST['upccode9'];
$vendor9=$POST['vendor9'];
$price9=$POST['price9'];
$saleprice9=$POST['saleprice9'];
$comment=$POST['comment'];
$submitted=$POST['submitted'];
$msgg2="";
$msgg3="";
$msgg4="";
$msgg5="";
$msgg6="";
$msgg7="";
$msgg8="";
$msgg9="";
if ($upccode2 != null)
{
$msgg2="\nItem #2 : ".$POST['upccode2']." : ".$POST['vendor2']." : ".$POST['price2']." : ".$POST['saleprice2'];
}
if ($upccode3 != null)
{
$msgg3="\nItem #3 : ".$POST['upccode3']." : ".$POST['vendor3']." : ".$POST['price3']." : ".$POST['saleprice3'];
}
if ($upccode4 != null)
{
$msgg4="\nItem #4 : ".$POST['upccode4']." : ".$POST['vendor4']." : ".$POST['price4']." : ".$POST['saleprice4'];
}
if ($upccode5 != null)
{
$msgg5="\nItem #5 : ".$POST['upccode5']." : ".$POST['vendor5']." : ".$POST['price5']." : ".$POST['saleprice5'];
}
if ($upccode6 != null)
{
$msgg6="\nItem #6 : ".$POST['upccode6']." : ".$POST['vendor6']." : ".$POST['price6']." : ".$POST['saleprice6'];
}
if ($upccode7 != null)
{
$msgg7="\nItem #7 : ".$POST['upccode7']." : ".$POST['vendor7']." : ".$POST['price7']." : ".$POST['saleprice7'];
}
if ($upccode8 != null)
{
$msgg8="\nItem #8 : ".$POST['upccode8']." : ".$POST['vendor8']." : ".$POST['price8']." : ".$POST['saleprice8'];
}
if ($upccode9 != null)
{
$msgg9="\nItem #9 : ".$POST['upccode9']." : ".$POST['vendor9']." : ".$POST['price9']." : ".$POST['saleprice9'];
}
$message="\nFagen Promo Request\n\nPromo Name : ".$POST['promo'].
"\nRequest By : ".$POST['submitted'].
"\nStore Number : ".$POST['store_number'].
"\nIncludes Stores: ".$POST['include'].
"\nStarting On : ".$POST['startdate'].
"\nEnding On : ".$POST['enddate'].
"\n : UPC CODE : Vendor : Price : Sale Price\nItem #1 : ".$POST['upccode']." : ".$POST['vendor']." : ".$POST['price']." : ".$POST['saleprice'].
"$msgg2$msgg3$msgg4$msgg5$msgg6$msgg7$msgg8$msgg9\n\nComments: ".$POST['comment'];
mail_notice($to,$from,$subject,$message);
}
function form()
{
?>
<form name="myform" action="<? echo $PHP_SELF; ?>" method="post">
<table>
<!-- <tr>
<td>Store Name:</td>
<td><input type="text" name="store_name" value="Fagen Pharmacy" size="40"></td>
</tr>
-->
<tr>
<td>Store # Requesting Promo:</td>
<td><select name="store_number">
<option>1</option>
<option>2</option>
<option>3</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>11</option>
<option>14</option>
<option>15</option>
<option>17</option>
<option>18</option>
<option>20</option>
<option>22</option>
<option>23</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>31</option>
<option>32</option>
<option>33</option>
<option>35</option>
<option>36</option>
<option>62</option>
</select>
</td>
</tr>
<tr>
<td>Promo Includes These Stores:</td>
<td><input type="text" ONKEYPRESS="return handleEnter(this, event)" name="include" size="40"></td>
</tr>
<tr>
<td>Promo Name (No Spaces):</td>
<td><input type="text" ONKEYPRESS="return handleEnter(this, event)" name="promo" size="40"></td>
</tr>
<tr>
<td>Start Date MM/DD/YYYY:</td>
<td><input type="text" ONKEYPRESS="return handleEnter(this, event)" name="startdate" size="12" value="MM/DD/YYYY"></td>
</tr>
<tr>
<td>End Date MM/DD/YYYY:</td>
<td><input type="text" ONKEYPRESS="return handleEnter(this, event)" name="enddate" size="12" value="MM/DD/YYYY"></td>
</tr>
<tr>
<td>UPC Code (Required):</td>
<td> Vendor Name ______________ Price __________ Sale Price ___________</td>
</tr>
<tr>
<td>Item #1:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice" size="30"></td>
</tr>
<tr>
<td>Item #2:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode2" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor2" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price2" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice2" size="30"></td>
</tr>
<tr>
<td>Item #3:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode3" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor3" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price3" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice3" size="30"></td>
</tr>
<tr>
<td>Item #4:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode4" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor4" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price4" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice4" size="30"></td>
</tr>
<tr>
<td>Item #5:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode5" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor5" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price5" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice5" size="30"></td>
</tr>
<tr>
<td>Item #6:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode6" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor6" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price6" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice6" size="30"></td>
</tr>
<tr>
<td>Item #7:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode7" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor7" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price7" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice7" size="30"></td>
</tr>
<tr>
<td>Item #8:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode8" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor8" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price8" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice8" size="30"></td>
</tr>
<tr>
<td>Item #9:<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="upccode9" size="14"></td>
<td> <input type="text" ONKEYPRESS="return handleEnter(this, event)" name="vendor9" size="30">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="price9" size="14">
<input type="text" ONKEYPRESS="return handleEnter(this, event)" name="saleprice9" size="30"></td>
</tr>
<tr>
<td>Amount markdown, Percentage</td><td> Off, BOGO, Mix and Match Promo, Etc.</td>
</tr>
<tr>
<td>If multi unit discount would need </td><td> to know - Buy 3 for 9.99</td>
</tr>
<tr>
<td>Submitted By (Required):</td>
<td><input type="text" ONKEYPRESS="return handleEnter(this, event)" name="submitted" size="40"></td>
</tr>
<tr>
<td>Comments:</td>
<td><textarea cols="40" rows="5" ONKEYPRESS="return handleEnter(this, event)" name="comment"></textarea></td>
</tr>
<tr>
<td colspan="2" align="center"><input type="submit" name="Mysubmit" value="Send"><input type="reset" value="Clear"></td>
</tr>
</table>
</form>
<? }
function mail_notice($to,$from,$subject,$message)
{
$email = $to;
mail ($email,$subject,$message,
"From: $from\r\n" .
"Reply-To: $from\r\n" .
"X-Mailer: PHP/" . phpversion());
}
function filter_html($text)
{
// First strip all html tags
$text=strip_tags($text);
return $text;
}
function format_timestamp($ts)
{
return substr($ts,4,2)."/".substr($ts,6,2)."/".substr($ts,0,4)." ".
substr($ts,8,2).":".substr($ts,10,2).":".substr($ts,12,2);
}
?>