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/* heres the html */
<form method="post" action="form-process-image-request.asp" name="myform">
<div class="contactwrap">
<table class="contactable">
<tr>
<td><strong>First Name:</strong> <span class="highlight">*</span></td>
<td><input type="text" size="38" name="FirstName" /></td>
</tr>
<tr>
<td><strong>Last Name:</strong> <span class="highlight">*</span></td>
<td><input type="text" size="38" name="LastName" /></td>
</tr>
<tr>
<td><strong>Title:</strong></td>
<td><input type="text" size="38" name="Title" /></td>
</tr>
<tr>
<td><strong>Company:</strong> <span class="highlight">*</span></td>
<td><input type="text" size="38" name="Company" /></td>
</tr>
<tr>
<td><strong>Address:</strong></td>
<td><input type="text" size="38" name="Location" /></td>
</tr>
<tr>
<td><strong>Email:</strong> <span class="highlight">*</span></td>
<td><input type="text" size="38" name="Email" /></td>
</tr>
<tr>
<td><strong>Phone:</strong> <span class="highlight">*</span></td>
<td><input type="text" size="38" name="Phone" /></td>
</tr>
</table>
</div><!-- end contactwrap -->
<div class="contactwrap">
<table class="contactable">
<tr>
<td colspan="2"><strong>I'm requesting the following product images (select all that apply)</strong><br /><br /></td>
</tr>
<tr>
<td><input type="checkbox" name="OraQuickADVANCE" value="OraQuick ADVANCE Rapid HIV-1/2 Antibody Test" class="iebrdr"/></td>
<td>OraQuick ADVANCE® Rapid HIV-1/2 Antibody Test</td>
</tr>
<tr>
<td><input type="checkbox" name="OraSureOralSpecimen" value="OraSure HIV-1 Oral Specimen Collection Device" class="iebrdr"/></td>
<td>OraSure® HIV-1 Oral Specimen Collection Device</td>
</tr>
<tr>
<td><input type="checkbox" name="OraSureWesternBlot" value="OraSure HIV-1 Western Blot Kit" class="iebrdr"/></td>
<td>OraSure® HIV-1 Western Blot Kit</td>
</tr>
<tr>
<td><input type="checkbox" name="InterceptOralFluid" value="Intercept Oral Fluid Drug Test" class="iebrdr"/></td>
<td>Intercept® Oral Fluid Drug Test</td>
</tr>
<tr>
<td><input type="checkbox" name="QEDSalivaAlcohol" value="Q.E.D. Saliva Alcohol Test" class="iebrdr"/></td>
<td>Q.E.D.® Saliva Alcohol Test</td>
</tr>
<tr>
<td><input type="checkbox" name="HistoFreezer" value="Histofreezer Portable Cryosurgical System" class="iebrdr"/></td>
<td>Histofreezer® Portable Cryosurgical System</td>
</tr>
<tr>
<td><input type="checkbox" name="MICROPLATEForensic" value="MICRO-PLATE EIA & AUTO-LYTE Technology for Forensic Toxicology" class="iebrdr"/></td>
<td>MICRO-PLATE EIA & AUTO-LYTE® Technology for Forensic Toxicology</td>
</tr>
<tr>
<td><input type="checkbox" name="FreezenClear" value="Freeze 'n Clear Skin Clinic Advanced Wart Remover" class="iebrdr"/></td>
<td>Freeze 'n Clear Skin Clinic™ Advanced Wart Remover</td>
</tr>
<tr>
<td colspan="2"><br /><br /></td>
</tr>
<tr>
<td colspan="2"><strong>In the following formats (select all that apply)</strong><br /><br /></td>
</tr>
<tr>
<td><input type="checkbox" name="lowresgif" value="Low Resolution - GIF" class="iebrdr"/></td>
<td>Low Resolution - GIF</td>
</tr>
<tr>
<td><input type="checkbox" name="lowresjpg" value="Low Resolution - JPEG" class="iebrdr"/></td>
<td>Low Resolution - JPEG</td>
</tr>
<tr>
<td><input type="checkbox" name="hiresjpg" value="High Resolution - JPEG" class="iebrdr"/></td>
<td>High Resolution - JPEG</td>
</tr>
<tr>
<td><input type="checkbox" name="hirespng" value="High Resolution - PNG" class="iebrdr"/></td>
<td>High Resolution - PNG</td>
</tr>
</table>
</div><!-- end contactwrap -->
<div class="contactwrap">
<table class="contactable">
<tr>
<td><strong>Intended Purpose:</strong> <span class="highlight">*</span></td>
<td><input type="text" size="38" name="Purpose" /></td>
</tr>
</table>
</div><!-- end contactwrap -->
<input type="text" id="email_address" name="email_address" class="emailaddress" />
<input type="image" src="http://www.orasure.com/i/img_btn_submit.jpg" border="0" alt="Submit" id="contactsubmit" onClick="return validate_form( );"/>
</form>
/* heres the ASP */
<%@LANGUAGE="VBSCRIPT" CODEPAGE="1252"%>
<%
Dim spambot
spambot = Request.Form("email_address")
IF spambot = "" THEN
Set objMail = Server.CreateObject("CDO.Message")
objMail.Configuration.Fields("http://schemas.microsoft.com/cdo/configuration/sendusing") = 2
objMail.Configuration.Fields("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "localhost"
objMail.From = "me@myserver.com" ' change this to an email address
objMail.To = "me@myserver.com" ' change this to your email address
objMail.Subject = "OraSure.com - Product Image Request" ' change this to your subject
'Set the e-mail body format (HTMLBody=HTML TextBody=Plain)
'Set the e-mail body format (HTMLBody=HTML TextBody=Plain)
objMail.HTMLBody = "<font size=3 face=verdana>"
objMail.HTMLBody = objMail.HTMLBody & Replace(Request.Form("Details"), vbCrLf, "<br />") & "<br>" & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "First Name: " & "</strong>" & Request.form("FirstName") & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "Last Name: " & "</strong>" & Request.form("LastName") & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "Title: " & "</strong>" & Request.form("Title") & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "Company: " & "</strong>" & Request.form("Company") & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "Address: " & "</strong>" & Request.form("Location") & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "Email: " & "</strong>" & Request.form("Email") & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "Phone: " & "</strong>" & Request.form("Phone") & "<br>" & "<br>" & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "I'm requesting the following product images: " & "</strong>" & "<br>" & Request.form("OraQuickADVANCE") & "<br>" & Request.form("OraSureOralSpecimen") & "<br>" & Request.form("OraSureWesternBlot") & "<br>" & Request.form("InterceptOralFluid") & "<br>" & Request.form("QEDSalivaAlcohol") & "<br>" & Request.form("HistoFreezer") & "<br>" & Request.form("MICROPLATEForensic") & "<br>" & Request.form("FreezenClear") & "<br>" & "<br>" & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "In the following formats: " & "</strong>" & "<br>" & Request.form("lowresgif") & "<br>" & Request.form("lowresjpg") & "<br>" & Request.form("hiresjpg") & "<br>" & Request.form("hirespng") & "<br>" & "<br>" & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<strong>" & "Intended Purpose: " & "</strong>" & "<br>" & Request.form("Purpose") & "<br>" & "<br>" & "<br>"
objMail.HTMLBody = objMail.HTMLBody & "<br>" & "<br>" & "Sent at " & Now() & "</font>"
objMail.Send()
Set objMail = Nothing
ELSE
Response.write("SPAM")
END IF
%>
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