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| 09/09/2008 at 10:50AM PDT, ID: 23716509 |
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<%
if request.form("Submit4") = "Submit Form" then
sName = request.form("Name")
sEmail = request.form("Email")
sAddress1 = request.form("Address1")
sAddress2 = request.form("Address2")
sPhone = request.form("Phone")
sCity = request.form("City")
sFax = request.form("Fax")
sState = request.form("State")
sZip = request.form("Zipcode")
sPoemTitle = request.form("PoemTitle")
sBookTitle = request.form("BookTitle")
sAuthor = request.form("Author")
sTitleofWork = request.form("TitleofWork")
sPrice = request.form("Price")
sTypeofWork = request.form("TypeofWork")
sBinding = request.form("Binding")
sInclusionAuthor = request.form("InclusionAuthor")
sPubDate = request.form("PubDate")
sPublisher = request.form("Publisher")
sPrintRun = request.form("PrintRun")
sRights = request.form("Rights")
sTypeofShow = request.form("TypeofShow")
sCallLetters = request.form("CallLetters")
sTypeofBroadcast = request.form("TypeofBroadcast")
sWebAddress = request.form("WebAddress")
sNameofHost = request.form("NameofHost")
sBroadcastDate = request.form("BroadcastDate")
sCompany = request.form("Company")
sNumberToCopy = request.form("NumberToCopy")
sInstructor = request.form("Instructor")
sNumberofPackets = request.form("NumberofPackets")
sTermStart = request.form("TermStart")
sSchool = request.form("School")
sCourseNumber = request.form("CourseNumber")
sOtherRequest = request.form("OtherRequest")
sBody = "The following information was submitted on: " & Now & vbcrlf & vbcrlf & _
"Name: " & sName & vbcrlf & _
"Email: " & sEmail & vbcrlf & _
"Address: " & sAddress1 & vbcrlf & _
"Address2: " & sAddress2 & vbcrlf & _
"Phone: " & sPhone & vbcrlf & _
"City: " & sCity & vbcrlf & _
"Fax: " & sFax & vbcrlf & _
"State: " & sState & vbcrlf & _
"Zip: " & sZip & vbcrlf & _
"Title of story selected: " & sPoemTitle & vbcrlf & _
"Title of book(s) from which story is selected: " & sBookTitle & vbcrlf & _
"Author: " & sAuthor & vbcrlf & _
"Title of Work: " & sTitleofWork & vbcrlf & _
"Price: " & sPrice & vbcrlf & _
"Type of Work: (e.g., anthology): " & sTypeofWork & vbcrlf & _
"Binding: " & sBinding & vbcrlf & _
"Author / Editor: " & sInclusionAuthor & vbcrlf & _
"Publication Date: " & sPubDate & vbcrlf & _
"Publisher: " & sPublisher & vbcrlf & _
"Print Run: " & sPrintRun & vbcrlf & _
"Rights: (e.g., North American, World, etc.): " & sRights & vbcrlf & _
"Type of Show: " & sTypeofShow & vbcrlf & _
"Call Letters: " & sCallLetters & vbcrlf & _
"Type of Broadcast: " & sTypeofBroadcast & vbcrlf & _
"Web Address: " & sWebAddress & vbcrlf & _
"Name of Host: " & sNameofHost & vbcrlf & _
"Broadcast Date: " & sBroadcastDate & vbcrlf & _
"Company: " & sCompany & vbcrlf & _
"Number of pages to be photocopied: " & sNumberToCopy & vbcrlf & _
"Instructor: " & sInstructor & vbcrlf & _
"Number of packets to be printed: " & sNumberofPackets & vbcrlf & _
"Start of Term: " & sTermStart & vbcrlf & _
"College or University: " & sSchool & vbcrlf & _
"Course Number: " & sCourseNumber & vbcrlf & _
"Other Request: " & sOtherRequest & vbcrlf
Set Mail = Server.CreateObject("Persits.MailSender")
Mail.Host = "135.11.12.15"
Mail.From = "customerservice@hcibooks.com"
Mail.FromName = "HCIBooks.com"
Mail.AddAddress "terryy@hcibooks.com"
'Mail.AddAddress "permissions@hcibooks.com"
'Mail.AddCC "hci@permissionscompany.com"
'Mail.AddCC "hci@hcibooks.com"
'Mail.AddBCC "ben@activeinternet.com"
Mail.Subject = "HCI Permissions"
Mail.Body = sBody
Mail.Send
Set Mail = Nothing
sMsg = "Your request has been submitted."
else
sMsg = ""
end if
%>
<form name="form2" method="post" action="<%= Request.ServerVariables("SCRIPT_NAME") %>">
<table width="530" border="0" cellspacing="0" cellpadding="2" class="sidebox">
<tr>
<td><strong><font color="#FF0000"><%= sMsg %></font></strong></td>
</tr>
<tr>
<td height="358" colspan="2" class="header">
<div align="center"><strong>Permissions</strong>
</div>
<p> Thank you for your interest in using work published by Health Communications,
Inc. To protect copyright and to ensure that our authors are paid
for re-publication and dissemination of their work, we require a Permissions
Contract to stipulate and validate the terms and conditions of use.
Charges vary depending upon usage.<br>
We receive requests to print stories and excerpts in many different
media.</p>
<p> We encourage certain personal uses—such as emailing a story
to a family member or friend—that do not require specific permission.
We do require that such use be appropriately acknowledged. The following
credit line must be included with the story or excerpt:</p>
<blockquote>
<p> "Title of Story" from "Title of Book," copyright
"Date" by "Author's Name," HCI, The Life Issues
Publisher, www.hcibooks.com. </p>
</blockquote>
<p> If you have any questions as to whether your proposed use of Health
Communications, Inc.'s material is subject to existing copyright restrictions,
please contact us.</p>
</td>
</tr>
<tr>
<td height="31" colspan="2" class="header"> <p align="center"><strong>Contract
for Permissions </strong> </p></td>
</tr>
<tr>
<td class="header">Your Contact Information</td>
<td width="269"> </td>
</tr>
<tr>
<td width="253"> Name:<br> <input name="Name" type="text" size="50"> </td>
<td width="269"> Email:<br> <input name="Email" type="text" size="40">
</td>
</tr>
<tr>
<td width="253"> Address:<br> <input name="Address1" type="text" size="50">
<br> <input name="Address2" type="text" size="50"> </td>
<td width="269"> Phone:<br> <input type="text" name="Phone"> </td>
</tr>
<tr>
<td width="253"> City:<br> <input name="City" type="text" size="50"> </td>
<td width="269"> Fax:<br> <input type="text" name="Fax"> </td>
</tr>
<tr>
<td width="253"> State:<br> <input type="text" name="State"> </td>
<td width="269">Zip:<br> <input name="Zipcode" type="text" size="10"></td>
</tr>
<tr>
<td colspan="2"> <hr noshade size="1"> </td>
</tr>
<tr>
<td colspan="2"> Title of story selected:<br> <input type="text" name="PoemTitle" size="90">
</td>
</tr>
<tr>
<td colspan="2"> Title of book(s) from which story is selected: <br> <input type="text" name="BookTitle" size="90">
</td>
</tr>
<tr>
<td colspan="2"> Author:<br> <input type="text" name="Author" size="50">
</td>
</tr>
<tr>
<td colspan="2"> <hr noshade size="1"> </td>
</tr>
<tr>
<td colspan="2" class="sideboxhead">If this request is for inclusion in
book form, please fill out the following information:</td>
</tr>
<tr>
<td width="253"> Title of Work:<br> <input name="TitleofWork" type="text" size="40">
</td>
<td width="269"> Price:<br> <input type="text" name="Price"> </td>
</tr>
<tr>
<td width="253"> Type of Work: (e.g., anthology)<br> <input name="TypeofWork" type="text" size="40">
</td>
<td width="269"> Binding:<br> <input type="text" name="Binding"> </td>
</tr>
<tr>
<td width="253"> Author / Editor:<br> <input name="InclusionAuthor" type="text" size="40">
</td>
<td width="269"> Publication Date:<br> <input type="text" name="PubDate">
</td>
</tr>
<tr>
<td width="253"> Publisher:<br> <input name="Publisher" type="text" size="40">
<br> <span class="caption">If you are without a publisher at this point,
please re-apply for permission when the publisher of your manuscript
has been named. </span> </td>
<td width="269" valign="top"> Print Run:<br> <input type="text" name="PrintRun">
<br>
Rights: (e.g., North American, World, etc.)<br> <input type="text" name="Rights">
</td>
</tr>
<tr>
<td colspan="2"> <hr noshade size="1"> </td>
</tr>
<tr>
<td colspan="2" class="sideboxhead">If this request is for broadcast or
website posting please fill out the following relevant information:</td>
</tr>
<tr>
<td width="253"> Type of Show:<br> <input name="TypeofShow" type="text" size="40">
</td>
<td width="269"> Call Letters:<br> <input name="CallLetters" type="text" size="40">
</td>
</tr>
<tr>
<td width="253"> Type of Broadcast:<br> <input name="TypeofBroadcast" type="text" size="40">
</td>
<td width="269"> Web Address:<br> <input name="WebAddress" type="text" size="40">
</td>
</tr>
<tr>
<td width="253"> Name of Host:<br> <input name="NameofHost" type="text" size="40">
</td>
<td width="269"> Broadcast Date:<br> <input type="text" name="BroadcastDate">
</td>
</tr>
<tr>
<td width="253" height="40"> Company:<br> <input name="Company" type="text" size="40">
</td>
<td width="269" height="40"> </td>
</tr>
<tr>
<td colspan="2"> <hr noshade size="1"> </td>
</tr>
<tr>
<td colspan="2" class="sideboxhead">If this request is for a student packet,
please fill out the following information:</td>
</tr>
<tr>
<td> Number of pages to be photocopied:<br> <input type="text" name="NumberToCopy">
</td>
<td> Instructor:<br> <input name="Instructor" type="text" size="40"> </td>
</tr>
<tr>
<td> Number of packets to be printed:<br> <input type="text" name="NumberofPackets">
</td>
<td> Start of Term:<br> <input type="text" name="TermStart"> </td>
</tr>
<tr>
<td> College or University:<br> <input name="School" type="text" size="40">
</td>
<td> Course Number:<br> <input type="text" name="CourseNumber"> </td>
</tr>
<tr>
<td colspan="2"> <hr noshade size="1"> </td>
</tr>
<tr>
<td colspan="2" class="sideboxhead">For other kinds of permission requests,
or to provide more details about the<br>
information submitted above, please enter the information below:</td>
</tr>
<tr>
<td colspan="2"> <textarea name="OtherRequest" cols="65" rows="10"></textarea>
</td>
</tr>
<tr>
<td> <input type="submit" name="Submit4" value="Submit Form" class="body">
</td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
</tr>
</table>
</FORM>
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