addValidation("anm","req","Association Name :"); $validator->addValidation("con","req","Contact Name :"); $validator->addValidation("add","req","Address :"); $validator->addValidation("cit","req","City :"); $validator->addValidation("sta","req","State :"); $validator->addValidation("zip","req","Zip :"); $validator->addValidation("ph3","req","Valid Phone :"); $validator->addValidation("eml","email","Please enter a valid email :"); $validator->addValidation("eml","req","Valid Email Address :"); $validator->addValidation("met","req","Type of Meeting :"); $validator->addValidation("num","req","# of Attendees :"); $validator->addValidation("loc","req","Meeting Location :"); $validator->addValidation("dmn","req","Meeting Month :"); $validator->addValidation("ddy","req","Meeting Day :"); $validator->addValidation("dyr","req","Meeting Year :"); $validator->addValidation("lor","req","Attendee Low Estimate :"); $validator->addValidation("avr","req","Attendee Average Estimate :"); $validator->addValidation("hir","req","Attendee High Estimate :"); $validator->addValidation("per","req","Attendee Type :"); $validator->addValidation("pln","req","Planning Sessions :"); $validator->addValidation("val","req","Validation Code"); if($validator->ValidateForm()) { //$to = "etoddt@gmail.com"; $to = "heinz@americansocietyap.org, cameront@americansocietyap.org, hans@americansocietyap.org"; $subject = "Improved Patient Care Speaker Request Form"; $from = "requestspeaker@improvedpatientcare.org"; $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)){ $output = '

EMAIL SENT: Please allow 24-48 hours for a representative to contact you regarding your inquiry.

'; $reset = 'reset'; } } else { $output = "
"; $output .= "

ERROR - PLEASE ENTER:
"; $error_hash = $validator->GetErrors(); foreach($error_hash as $inpname => $inp_err) { $output .= "$inp_err   "; } $output .= "

^ Click on the Links Above to Find the Required Form ^
"; } } $body_id = 'schedul'; $title = 'Schedule a Speaker'; require_once('header.php'); ?>


Contact Information

Assocation
Name:
Address:
City:
State:
Zip:
Contact Name:
Contact Title:
Phone #:
Fax #:
Email Address:
Web Site:

Meeting Information

Meeting type:
# of Attendees:
Meeting Location:
Meeting Date:
Month Day Year
Apprx. Times:
How many attend your meetings?
Low #: Average #: High #:
Who attends and approximate % of each group?
What type of session are you considering us for?
When do you meet to plan your meetings/conferences?
Would you consider having a break for Q&A after our presentation?
Are you capable of accomodating a morning session?
Are you capable of accomodating a two-hour session?
Other information you would like us to know about your organization?
Security Question - Please Type the Letters at Right =