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Fill out a form and E-mail it.

This page contains 3 pages of info broken up into 3 boxes below.. The first section you fill out the form. The second section you check what you filled out. On the third section the email gets sent. The javascript checks that certian boxes are filled out. The PHP code will update the form fields if you go back and forth from the check page and the entry page. Put these three different sections below in three different files.

Page 1

<?
// Initialize session
session_start();
?>

<html>
<head>
<script language="JavaScript">
<!--

function checkFields()
{
    if (document.metsign.billtoccname.value == 0)
    {
        alert("Please provide us with the name that appears on the Credit Card.\n"); 
        return false;
    }
    if (document.metsign.billtoaddress1.value == 0)
    {
        alert("Please provide us with the billing address of the Credit Card.\n");    
        return false;
    }
    if (document.metsign.billtocity.value == 0)
    {
        alert("Please provide us with your city.\n");
        return false;
    }
    if (document.metsign.billtostate.value == 'select_state')
    {
        alert("Please provide us with your state.\n");
        return false;
    }
    if (document.metsign.billtozip.value == 0)
    {
        alert("Please provide us with your zip.\n");
        return false;
    }
    if (document.metsign.billtophone.value == 0)
    {
        alert("Please provide us with your phone number.\n");
        return false;
    }
    if (!document.metsign.cctype[0].checked && !document.metsign.cctype[1].checked && !document.metsign.cctype[2].checked)
    {
        alert("Please choose a Credit Card type.\n");
        return false;
    }
    if (document.metsign.ccnumber.value == 0)
    {
        alert("Please provide us with your credit card number.\n");
        return false;
    }
    if (document.metsign.ccexpmonth.value == 'select_month')
    {
        alert("Please provide us with your Credit Cards expiration month.\n");
        return false;
    }
    if (document.metsign.ccexpyear.value == 'select_year') 
    {
        alert("Please provide us with your Credit Cards expration year\n");
        return false;
    }
    if (document.metsign.billtosubscription.value == 'select_sub')
    {
        alert("Please provide us with your subscription type.\n");
        return false;
    }
}
// -->
</script>
</head>
</body>
<form action="formpg2.php" method="POST" name="metsign">
<p>Please provide us with the credit card information below.</p>

<b>User-Info:</b><br />

First Name<input type="text" name="userfirstname" size="29" maxlength="29"<?
if (session_is_registered("userfirstname") == true) { print "value =\"$userfirstname\""; } else { print "value=\"\""; }
?>><br />
Last Name<input type="text" name="userlastname" size="29" maxlength="29"<?
if (session_is_registered("userlastname") == true) { print "value =\"$userlastname\""; } else { print "value=\"\""; }
?>><br />

<b>Bill-To:</b><br />

Company Name<input type="text" name="billtocompanyname" size="29" maxlength="29"<?
if (session_is_registered("billtocompanyname") == true) { print "value =\"$billtocompanyname\""; } else { print "value=\"\""; }
?>><br />

Name on Credit Card<input type="text" name="billtoccname" size="29" maxlength="29"<?
if (session_is_registered("billtoccname") == true) { print "value =\"$firstname $billtoccname\""; } else { print "value=\"\""; }
?>><br />

Address 1<input type="text" name="billtoaddress1" size="29" maxlength="29"<?
if (session_is_registered("billtoaddress1") == true) { print "value =\"$billtoaddress1\""; } else { print "value=\"\""; }
?>><br />

Address 2<input type="text" name="billtoaddress2" size="29" maxlength="29"<?
if (session_is_registered("billtoaddress2") == true) { print "value =\"$billtoaddress2\""; } else { print "value=\"\""; }
?>><br /> 

City<input type="text" name="billtocity" size="29" maxlength="29"<?
if (session_is_registered("billtocity") == true) { print "value =\"$billtocity\""; } else { print "value=\"\""; }
?>><br /> 

State<select name="billtostate">
<option selected value="select_state">Select</option>

<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>

<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>

<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>

<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>

<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>

<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>

<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>

<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>

<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>

<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>

<option value="WY">WY</option>
</select><br />

Zip Code<input type="text" name="billtozip" size="10" maxlength="12"<?
if (session_is_registered("billtozip") == true) { print "value =\"$billtozip\""; } else { print "value=\"\""; }
?>><br /> 

Phone Number<input type="text" name="billtophone" size="15" maxlength="15"<?
if (session_is_registered("billtophone") == true) { print "value =\"$billtophone\""; } else { print "value=\"\""; }
?>><br />


Type of credit card<br><br>

Visa<input type="radio" name="cctype" value="Visa"><br>

Mastercard<input type="radio" name="cctype" value="Mastercard"><br>

Discover<input type="radio" name="cctype" value="Discover"><br />

Credit Card Number<input type="text" name="ccnumber" size="16" maxlength="16"<?
if (session_is_registered("ccnumber") == true) { print "value =\"$ccnumber\""; } else { print "value=\"\""; }
?>><br />

Credit Card Expiration <select name="ccexpmonth">
<OPTION selected value="select_month">Select Month</option>

<OPTION value="1">1</option>
<OPTION value="2">2</option>
<OPTION value="3">3</option>
<OPTION value="4">4</option>
<OPTION value="5">5</option>

<OPTION value="6">6</option>
<OPTION value="7">7</option>
<OPTION value="8">8</option>
<OPTION value="9">9</option>
<OPTION value="10">10</option>

<OPTION value="11">11</option>
<OPTION value="12">12</option>
</select>

<select name="ccexpyear">
<OPTION selected value="select_year">Select Year</option>

<OPTION value="2001">2001</option>
<OPTION value="2002">2002</option>
<OPTION value="2003">2003</option>
<OPTION value="2004">2004</option>
<OPTION value="2005">2005</option>

<OPTION value="2006">2006</option>
<OPTION value="2007">2007</option>
<OPTION value="2008">2008</option>
<OPTION value="2009">2009</option>
<OPTION value="2010">2010</option>

<OPTION value="2011">2011</option>
<OPTION value="2012">2012</option>
</select><br />

<select name="billtosubscription">
<OPTION selected value="select_sub">Select Subscription</option>

<OPTION value="Q1">Quarterly Subscription</option>
<OPTION value="Y1">Yearly Subscription</option>
</select><br />

<center><input type="submit" name="submit" value="Next -->" onClick="return checkFields();"></center> 

</form>
</html>

Page 2

<?
// Initialize session
session_start();

session_register("userfirstname");
$GLOBALS['userfirstname']=$HTTP_POST_VARS['userfirstname'];

session_register("userlastname");
$GLOBALS['userlastname']=$HTTP_POST_VARS['userlastname'];

session_register("billtocompanyname");
$GLOBALS['billtocompanyname']=$HTTP_POST_VARS['billtocompanyname'];

session_register("billtoccname");
$GLOBALS['billtoccname']=$HTTP_POST_VARS['billtoccname'];

session_register("billtoaddress1");
$GLOBALS['billtoaddress1']=$HTTP_POST_VARS['billtoaddress1'];

session_register("billtoaddress2");
$GLOBALS['billtoaddress2']=$HTTP_POST_VARS['billtoaddress2'];

session_register("billtocity");
$GLOBALS['billtocity']=$HTTP_POST_VARS['billtocity'];

session_register("billtostate");
$GLOBALS['billtostate']=$HTTP_POST_VARS['billtostate'];

session_register("billtozip");
$GLOBALS['billtozip']=$HTTP_POST_VARS['billtozip'];

session_register("billtophone");
$GLOBALS['billtophone']=$HTTP_POST_VARS['billtophone'];

session_register("cctype");
$GLOBALS['cctype']=$HTTP_POST_VARS['cctype'];

session_register("ccnumber");
$GLOBALS['ccnumber']=$HTTP_POST_VARS['ccnumber'];

session_register("ccexpmonth");
$GLOBALS['ccexpmonth']=$HTTP_POST_VARS['ccexpmonth'];

session_register("ccexpyear");
$GLOBALS['ccexpyear']=$HTTP_POST_VARS['ccexpyear'];

session_register("billtosubscription");
$GLOBALS['billtosubscription']=$HTTP_POST_VARS['billtosubscription'];

?>

<html><center><h3>After you have verfied this information is correct please click the finish button.</h3></center><br>
<center><h3>If you need to make changes click the back button on your browser</h3></center><br>

<?
print "<center><table border=\"1\">

<tr><td><b>Users First Name:</b> $userfirstname</td></tr>

<tr><td><b>Users Last Name:</b> $userlastname</td></tr>

<tr><td><b>Met Cert #:</b> $metcertnum</td></tr>

<tr><td><b>Company Name:</b> $billtocompanyname</td></tr>

<tr><td><b>Name on Credit Card:</b> $billtoccname</td></tr> <tr><td><b>Address 1:</b> $billtoaddress1</td></tr>

<tr><td><b>Address 2:</b> $billtoaddress2</td></tr> <tr><td><b>City:</b> $billtocity</td></tr>

<tr><td><b>State:</b> $billtostate</td></tr> <tr><td><b>Zip:</b> $billtozip</td></tr>

<tr><td><b>Phone Number:</b> $billtophone</td></tr> <tr><td><b>Credit Card Type:</b> $cctype</td></tr>

<tr><td><b>Credit Card Number:</b> $ccnumber</td>

<tr><td><b>Credit Card Expration:</b> $ccexpmonth/$ccexpyear</td></tr>

<tr><td><b>Subscription Type:</b> $billtosubscription</td></tr>

</table></center>

<center> <form><input type=\"button\" name=\"Edit Information\" value=\"Finish\" onClick=\"document.location.href='formpg3.php';\">

<html>"

?>

Page 3

<? 
session_start(); // initialize session

// setup email addributes \\
$testemail = "jmcsorley@assurenet.com";
$emailsubject = "Form Information";
$emailfrom = "From: ccinfo@here.com";
$body = "
-=User Info=-\n\n
Name: $firstname $lastname\n

-=Bill-To Info=-\n\n
Bill-To Company Name: $billtocompanyname\n
Bill-To Credit Card Name: $billtoccname\n
Bill-To Address1: $billtoaddress1\n
Bill-To Address2: $billtoaddress2\n
Bill-To City: $billtocity\n
Bill-To State: $billtostate\n
Bill-To Zip: $billtozip\n
Bill-To Phone: $billtophone\n
Bill-To Credit Card Type: $cctype\n
Bill-To Credit Card Number: $ccnumber\n
Bill-To Credit Card Exp: $ccexpmonth/$ccexpyear\n
Bill-To Subscription: $billtosubscription\n
";

//send the email. I suggest if your sending real credit card info you 
//encrypt the e-mail. see www.pantz.org for an example
mail ($testemail, $emailsubject, $body, $emailfrom);

print "<html><center>Thanks for filling out the form.</center></html>";

?>