Bipolar Membership Form

<%@LANGUAGE="VBSCRIPT"%> <% if Request.Form("FFSubmitted") = "yes" then Dim BodyString Dim objCDO Dim RedirectURL Dim FormFields Dim arrFormFields FormFields = "First~Last~Degree~Title~Organization~Department~Street1~Street2~City~state~Zip~Country~WorkPhone~HomePhone~Fax~Email~Level~OtherAmount~CardType~CreditCardNum~CCExpDate~SecurityCode~NameOnCard" If FormFields <> "" Then arrFormFields = split(FormFields,"~") End If Set objCDO = Server.CreateObject("CDONTS.NewMail") objCDO.From = "chadd@isbd.org" objCDO.To = "daversacd@msx.upmc.edu" objCDO.Cc = "sevet@aol.com" objCDO.Bcc = "chaddvrs@verizon.net" objCDO.Subject = "test donation" BodyString = Replace("New donation form has been recieved.","~",chr(13) & chr(10) )& chr(13) If FormFields <> "" Then For Each item In arrFormFields BodyString = BodyString & item & ": " & Request.Form(item) & chr(13) Next End If objCDO.Body = BodyString objCDO.BodyFormat = 1 objCDO.MailFormat = 1 objCDO.Send Set objCDO = Nothing RedirectURL = "/donation_thanks.htm" If RedirectURL <> "" then If Request.QueryString <> "" Then response.redirect(RedirectURL & "?" & Request.QueryString) else response.redirect(RedirectURL) end If end if end if %> <% MM_EditAction = CStr(Request("URL")) If (Request.QueryString <> "") Then MM_EditAction = MM_EditAction & "?" & Request.QueryString End If %> Bipolar Membership Form

First Name:

Last Name:

Degree:

Title:

Affiliation:

Department:

Street Address:

City:

State/Province:

Zip:

Country:

Work Phone:

Home Phone:

Fax:

E-Mail Address:

Donation Information

Donation Level:

THANK YOU FOR YOUR CONTINUED SUPPORT!