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9.8
Assigning Select Tag value to PHP vairable

Asked by neonate928 in PHP Scripting Language

I have created an online application. Once the user hits submit and all fields are validated using Javascript I want the application to be emailed to me. Through the application I have select drop down boxes, check boxes and radio buttons. My question is how do I check to see what option is selected in the drop down boxes and assign its value to the PHP variable?

I would also like to know the same for the radio buttons and check box buttons. Thanks a million!
View the Solution FREE for 30 Days
         
           
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             HTML CODE:
--------------------
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<link rel="stylesheet" type="text/css" href="CSS/layout.css">
<link rel="stylesheet" type="text/css" href="CSS/application.css">
 
<script type="text/javascript" src="Scripts/validate.js"></script>
 
<title>RN Resources, LLC</title>
<style type="text/css">
<!--
.style1 {color: #CCCCCC}
-->
</style>
</head>
 
<body class="oneColFixCtrHdr">
 
<div id="container">
  <div id="header">
    <!--Header jpg will display here.-->
    <div id="navMenu">
    			<ul>
        			<li><a href="index.html" class="home"> </a></li>
                    <li><a href="faq.html" class="faq"> </a></li>
        			<li><a href="about.html" class="about"> </a></li>
    			</ul>
    <!-- end #navMenu --></div>
    <!-- end #header --></div>
  <div id="appContent">
        	<table width = "700" border="0" align="left" celpadding="" cellspacing="1">
            	<form name="applicationform" onsubmit="return validate(this)" action="#"> 
            	<table width="100%" border="0" cellspacing="5" cellpadding="3">
                <!--Personal Information -->
                <table><!--Table for Title Layout-->
                <tr>
                    <td><strong>Personal Information</strong></td>
                </tr>
                <tr>
                	<td>* donates required fields</td>
                </tr>
                </table>
                <table><!--Table for input layout-->
                <tr>
                	<td>&nbsp;</td>
                </tr>
                <tr>
                    <td width="42%">*Last Name</td>
                    <td width="42%">*First Name</td>
                    <td width="16%">*Middle Initial:</td>
              	</tr>
                <tr>
                    <td><input name="lastname" type="text" id="lastname" size="25" maxlength="25" class="reqd"/></td>
                    <td><input name="firstname" type="text" id="firstname" size="25" maxlength="25" class="reqd" /></td>
                    <td><input name="middlename" type="text" id="middlename" size="1" maxlength="1" class="reqd" /></td>
                </tr>
                <tr>
                    <td>Other names you are known under:</td>
                </tr>
                <tr>
                    <td><input name="oname" type"text" id="othername" size="38" /></td>
                </tr>
                <tr>
                    <td>*Primary Phone:</td>
                    <td>Secondary Phone:</td>
                </tr>
                <tr>
                    <td><input name="primaryphone" type="text" id="primaryphone" size="12" maxlength="12" class="reqd phone" />&nbsp;xxx-xxx-xxxx</td>
                    <td><input name="secondaryphone" type="text" id="secondaryphone" size="12" maxlength="12" class="secondary phone" />&nbsp;xxx-xxx-xxxx</td>
                </tr>
                <tr>
                    <td>*Email Address:</td>
                </tr>
                <tr>
                    <td><input name="appmail" type="text" id="appemail" size="25" maxlength"25" class="reqd email" /></td>
                </tr>
                <tr>
                    <td>Social Security Number: (OPITIONAL)</td>
                </tr>
                <tr>
                    <td><input name="socialnumber" type="text" id="socialnumber" size="10" maxlength="10"/>&nbsp; No dash's</td>
                </tr>
                <tr>
                    <td>*Discipline:</td>
                    <td>*Current Specialty:</td>
                    <td>*Years in Specialty:</td>
                </tr>
                <tr>
                    <td><select name="discipline" id="discipline" class="reqd">
                        <option value="selectdiscipline" >Please select a discipline...</option>
                        <option value="RN" class="disciplineRN">RN</option>
                        <option value="CNA" class="disciplineCNA">CNA</option>
                        </select></td>
                	<td><select name="specialty" id="specialty" class="reqd">
                        <option value="selectspeclty">Please select a specialty...</option>
                        <option value="MS">M/S</option>
                        <option value="ICU">ICU</option>
                        <option value="ER">ER</option>
                        <option value="Psych">Psych</option>
                        <option value="OB">OB</option>
                        <option value="Tele">Tele</option>
                        </select></td>
                    <td><select name="yearspecialty" id="yearsspecialty" class="reqd">
                        <option value="selectyears">Please select years...</option>
                        <option value="zerotwo">0 - 2</option>
                        <option value="twosix">2 - 6</option>
                        <option value="sixten">6 - 10</option>
                        <option value="plusten">10+</option>
                        </select></td>
                </tr>
                <tr>
                	<td>&nbsp;</td>
                </tr>
                <tr>
                    <td>*Have you ever worked as a traveler?:</td>
                </tr>
                <tr>
                    <td>Yes: <input type="radio" name="worked" value="yes" id="worked" > No: <input type="radio" name="worked" value="no" id="worked" checked="checked"></td>
                </tr>
                <tr>
                	<td>Date avaliable to work: (mm/dd/yyyy)</td>
                </tr>
                <tr>
                    <td><input name="avaliabledate" type="text" id="avaliabledate" size="10" maxlength="10" class="calendar" /></td>
                </tr>
                <tr>
                	<td>&nbsp;</td>
                </tr>
                </table>
                <!--End Personal Information-->
                <!-- Start Address Information -->
                <table>
                 <tr>
                    <td><strong>Address Information</strong></td>
                </tr>
                <tr>
                	<td>&nbsp;</td>
                </tr>
                </table>
                <table width="70%" border="0" cellspacing="3" cellpadding="3">
                <tr>
                    <td width="25%">Current Address:</td>
                    <td width="25%"></td>
                    <td width="20%"></td>
                 </tr>
                 <tr>
                    <td>*Street Address:</td>
                    <td>*Country</td>
                 </tr>
                 <tr>
                    <td><input name="currentaddress" type="text" id="currentaddress" size="25" maxlength="25" class="reqd"/></td>
                    <td><input name="currentcountry" type="text" id="currentcountry" size="25" maxlength="25" class="reqd"/></td>
                 </tr>
                 <tr>
                    <td>*City</td>
                    <td>*State/Province:</td>
                    <td>*Zip/Postal code:</td>
                 </tr>
                 <tr>
                    <td><input name="currentcity" type="text" id="currentcity" size="25" maxlength="25" class="reqd" /></td>
                    <td><input name="currentstate" type="text" id="currentstate" size="25" maxlength="25" class="reqd" /></td>
                    <td><input name="currentzip" type="text" id="currentzip" size="5" maxlength="5" class="reqd" /></td>
                 </tr>
                 <tr>
                    <td>Permanent Address:</td>
                 </tr>
                 <tr>
                    <td>Street Address:</td>
                    <td>Country</td>
                 </tr>
                 <tr>
                    <td><input name="permanentaddress" type="text" id="permanentaddress" size="25" /></td>
                    <td><input name="permanentcountry" type="text" id="permanentcountry" size="25" /></td>
                 </tr>
                 <tr>
                    <td>City</td>
                    <td>State/Province:</td>
                    <td>Zip/Postal code:</td>
                 </tr>
                 <tr>
                    <td><input name="permanentcity" type="text" id="permanentcity" size="25"  /></td>
                    <td><input name="permanentstate" type="text" id="permanentstate" size="25"  /></td>
                    <td><input name="permanentzip" type="text" id="permanentzip" size="5" maxlength="5"  /></td>
                 </tr>
                 <tr>
                 	<td>&nbsp;</td>
                 </tr>
                 </table>
                 <!-- End Address information -->
                 <!-- Start Emegency Contact -->
                 <table width="60%" border="0" cellspacing="3" cellpadding="3"> 	
                 <tr>
                    <td width="20%"><strong>Emergency Contact</stong></td>
                    <td width="20%">
                    <td width="20%">
                 </tr> 
                 <tr>
                 	<td>&nbsp;</td>
                 </tr>    
                 <tr>
                    <td>Name of contact:</td>
                    <td>Relationship:</td>
                    <td>Phone:</td>
                 </tr>
                 <tr>
                    <td><input name="emergencyname" type="text" id="emergencyname" size="25" /></td>
                    <td><input name="emergencyrelation" type="text" id="emergencyrelation" size="25" /></td>
                    <td><input name="emergencyphone" type="text" id="emergencyphone" size="12" /></td>
                 </tr>
                 <tr>
                    <td>Street Address:</td>
                    <td>Country</td>
                 </tr>
                 <tr>
                     <td><input name="emergencyaddress" type="text" id="emergencyaddress" size="25" /></td>
                     <td><input name="emergencycountry" type="text" id="emergencycountry" size="25" /></td>
                 </tr>
                 <tr>
                     <td>City</td>
                     <td>State/Province:</td>
                     <td>Zip/Postal code:</td>
                 </tr>
                 <tr>
                     <td><input name="emergencycity" type="text" id="emergencycity" size="25"  /></td>
                     <td><input name="emergencystate" type="text" id="emergencystate" size="25"  /></td>
                     <td><input name="emergencyzip" type="text" id="emergencyzip" size="5"  maxlength="5" /></td>
                 </tr>
                 <tr>
                 	<td>&nbsp;</td>
                 </tr> 
           		 </table>
                 <!-- End Emergency Contact Information -->
                 <!-- Start License/Registaration/Certification --->
                 <table width="60%" border="0" cellspacing="3" cellpadding="3">
                 <tr>
                 	<td><strong>License:</strong></td>
                 </tr>
                 <tr>
                	<td>&nbsp;</td>
                </tr> 
                <tr>
                    <td>*License type:</td>
                    <td>*License number:</td>
                </tr>
                <tr>
                    <td><select name="firstlicense" id="firstlicense" class="reqd">
                        <option value="firstselectlicense">Please select a license type</option>
                        <option value="RN">RN</option>
                        <option value="CNA">CNA</option>
                        </select></td>
                    <td><input name="firstlicensenumber" type="text" id"firstlicensenumber" size="30" maxlength="30" class="reqd" /></td>
                </tr>
                <tr>
                    <td>*State/Province:</td>
                    <td>*Expiration date:</td>
                </tr>
                <tr>
                    <td><input type="text" name="firststatelicense" id="firststatelicense" size="25" maxlength="25" class="reqd" /></td>
                    <td><input type="text" name="firstexpirationlicense" id="firstexpiration" size="10"  maxlength="10" class="reqd"/></td>
                </tr>
                <tr>
                	<td>License type:</td>
                	<td>License number:</td>
                </tr>
                <tr>
                    <td><select name="secondlicense" id="secondlicense">
                        <option value="secondselectlicense">Please select a license type</option>
                        <option value="RN">RN</option>
                        <option value="CNA">CNA</option>
                        </select></td>
                    <td><input name="secondlicensenumber" type="text" id"secondlicensenumber" size="30" /></td>
                </tr>
                <tr>
                    <td>State/Province:</td>
                    <td>Expiration date:</td>
                </tr>
                <tr>
                    <td><input type="text" name="secondstatelicense" id="secondstatelicense" size="30" /></td>
                    <td><input type="text" name="secondexpirationlicense" id="secondexpiration" size="10"  /></td>
                </tr>
                <tr>
                	<td>&nbsp;</td>
                </tr>
                </table>
                <!-- End License Information -->
                <!-- Start Certification -->
                <table>
                 <tr>
                    <td><strong>Certification:</strong></td>
                </tr>
                <tr>
                	<td>&nbsp;</td>
                </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                <tr>
                	<td>Check applicable certifcations and enter expiration date (mm/dd/yyyy).</td>
                </tr>
                </table>
                <table width="50%" border="0" cellspacing="" cellpadding="3">
                <tr>
                    <td><input type="checkbox" name="ACLS" value="yes" id="ACLS" class="acls" />ACLS:</td>
                    <td><input type="text" name="aclsdate" id="aclsdate" size="10" maxlength="10" class="aclsdate" /></td>
                    <td><input type="checkbox" name="ENPC" value="yes" id="ENPC" class="enpc"/>ENPC:</td>
                    <td><input type="text" name="enpcdate" id="enpcdate" size="10" maxlength="10" class="enpcdate" /></td>
                </tr>
                <tr>
                    <td><input type="checkbox" name="BLS" value="yes" id="BLS" class="bls"/>BLS:</td>
                    <td><input type="text" name="blsdate" id="blsdate" size="10" maxlength="10" class="blsdate"/></td>
                    <td><input type="checkbox" name="FHM" value="yes" id="FHM" class="fhm"/>FHM:</td>
                    <td><input type="text" name="fhmdate" id="fhmdate" size="10" maxlength="10" class="fhmdate"/></td>
                </tr>
                <tr>
                    <td><input type="checkbox" name="CCRN" value="yes" id="CCRN" class="ccrn"/>CCRN:</td>
                    <td><input type="text" name="ccrndate" id="ccrndate" size="10" maxlength="10" class="ccrndate"/></td>
                    <td><input type="checkbox" name="NRP" value="yes" id="NRP" class="nrp"/>NRP:</td>
                    <td><input type="text" name="nrpdate" id="nrpdate" size="10" maxlength="10" class="nrpdate"/></td>
                </tr>
                <tr>
                    <td><input type="checkbox" name="CEN" value="yes" id="CEN" class="cen" />CEN:</td>
                    <td><input type="text" name="cendate" id="cendate" size="10" maxlength="10" class="cendate"/></td>
                    <td><input type="checkbox" name="PALS" value="yes" id="PALS" class="pals" />PALS:</td>
                    <td><input type="text" name="palsdate" id="palsdate" size="10" maxlength="10" class="palsdate"/></td>
                </tr>
                <tr>
                    <td><input type="checkbox" name="CHEMO" value="yes" id="CHEMO" class="chemo"/>CHEMO:</td>
                    <td><input type="text" name="chemodate" id="chemodate" size="10" maxlength="10" class="chemodate"/></td>
                    <td><input type="checkbox" name="RNC" value="yes" id="RNC" class="rnc"/>RNC:</td>
                    <td><input type="text" name="rncdate" id="rncdate" size="10" maxlength="10" class="rncdate"/></td>
                </tr>
                <tr>
                    <td><input type="checkbox" name="CNOR" value="yes" id="CNOR" class="cnor"/>CNOR:</td>
                    <td><input type="text" name="cnordate" id="cnordate" size="10" maxlength="10" class="cnordate"/></td>
                    <td><input type="checkbox" name="TNCC" value="yes" id="TNCC" class="tncc"/>TNCC:</td>
                    <td><input type="text" name="tnccdate" id="tnccdate" size="10" maxlength="10" class="tnccdate"/></td>
                </tr>
                <tr>
                    <td><input type="checkbox" name="CNRN" value="yes" id="CNRN" class="cnrn"/>CNRN:</td>
                    <td><input type="text" name="CNRNdate" id="CNRNdate" size="10" maxlength="10" class="cnrndate"/></td>
                    <td><input type="checkbox" name="Other" value="yes" id="other" class="other" />Other:</td>
                    <td><input type="text" name="otherdate" id="othherdate" size="10" maxlength="10" class="otherdate"/></td>
                    <td><input type="text" name="othertext" id="othertext" size="30" maxlength="30" class="othertxt"/></td>
                </tr>
                <tr>
                  	<td></td>
                    <td></td>
                    <td></td>
                    <td></td>
                	<td>Specify Certificate above.</td>
                </tr>
                </table>
                <table width="50%">
                <tr>
                	<td>Have you passed the NCLEX?</td>
                </tr>
                <tr>
                    <td>Yes: <input type="radio" name="NCLEX" value="yes" id="NCLEX" > No: <input type="radio" name="NCLEX" value="no" id="NCLEX" checked="checked"></td>
                </tr>
                <tr>
                	<td>&nbsp;</td>
                </tr>
                </table> 
                <!-- End Certification -->
                <!-- Start Additional Information -->
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td><strong>Additional Information</strong></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td>*Has your license or certification ever been investigated or suspended?</td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="30%">Yes: <input type="radio" name="licensesuspended" value="yes" id="licensesuspended" class="licensesuspended"> No: <input type="radio" name="licensesuspended" value="no" id="licensesuspended" ></td>
                        <td width="70%">If <strong>yes</strong>, please give details and current status: (Max 1000 char) 
                      <textarea cols="70" rows="3" class="txtlicensesuspended"></textarea> </td>
                	</tr>
               </table>
               <table width="100%" border="0" cellspacing="" cellpadding="3">
               		<tr>
                    	<td>*Have you ever been convicted of a crime other than a minor traffic violation?</td>
                    </tr>
                    <tr>
                    	<td><span class="style1">(Driving under the influence is not considered a minor traffic violation. Exceptions due to state employment law: Conviction(s) that have been sealed, expunged or eradicated and California Health & Safety Code 11357 (b) & (c), 11460(c), 11364, 11365, 11550 marijuana-related convictions over 2 years old, should not be revealed.)</span> </td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="30%">Yes: <input type="radio" name="convicted" value="yes" id="convicted" class="convicted" > No: <input type="radio" name="convicted" value="no" id="convicted"></td>
                        <td width="70%">If <strong>yes</strong>, please give details and current status: (Max 1000 char) 
                      <textarea cols="70" rows="3"></textarea> </td>
                	</tr>
                </table>
               	<table width="100%" border="0" cellspacing="" cellpadding="3">
               		<tr>
                    	<td>*Have you ever been named as a defendant in a professional liability action?</td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="30%">Yes: <input type="radio" name="liabilityaction" value="yes" id="liabilityaction" > No: <input type="radio" name="liabilityaction" value="no" id="liabilityaction"></td>
                        <td width="70%">If <strong>yes</strong>, please give details and current status: (Max 1000 char) 
                      <textarea cols="70" rows="3"></textarea> </td>
                	</tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
               		<tr>
                    	<td>*Are you either a U.S. Citizen or can you submit verification of your legal right to work in the U.S.?</td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="30%">Yes: <input type="radio" name="uscitizen" value="yes" id="uscitizen" > No: <input type="radio" name="uscitizen" value="no" id="uscitizen"></td>
                        <td width="70%">If <strong>no</strong>, please give details and current status: (Max 1000 char) 
                      <textarea cols="70" rows="3"></textarea> </td>
                	</tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
      			</table>
                <!-- End Additional Information -->
                <!-- Start Education -->
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td><strong>Education</strong></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                    <tr>
                        <td width="100%">*University/College name</td>
                    </tr>
                    <tr>
                    	 <td><input name="collegename" type="text" id="collegename" size="100" maxlength="100" class="reqd"/></td>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr> 
                        <td width="20%">*Graduation Date:</td>
                        <td width="80%">*Degree</td>
                    </tr>
                    <tr>
                    	<td><input name="graduationdate" type="text" id="graduationdate" size="10" maxlength="10" class="reqd"/>&nbsp;(mm/dd/yyyy)</td>
                        <td><input name="degree" type="text" id="degree" size="50" maxlength="50" class="reqd"/></td>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr> 
                        <td width="40%">*Major:</td>
                        <td width="20%"></td>
                        <td width="40%"></td>
                    </tr>
                    <tr>
                    	<td><input name="major" type="text" id="major" size="40" maxlength="40" class="reqd"/></td>
                    </tr>
                    <tr>
                    	<td>*City</td>
                        <td>*State/Province:</td>
                        <td>*Country:</td>
                    </tr>
                    <tr>
                    	<td><input name="collegecity" type="text" id="collegecity" size="40" maxlength="40" class="reqd"/></td>
                        <td><input name="colloegestate" type="text" id="collegestate" size="20" maxlength="20" class="reqd"/></td>
                        <td><input name="collegecountry" type="text" id="collegecountry" size="30" maxlength="30" class="reqd"/></td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                    <tr>
                        <td width="100%">University/College name</td>
                    </tr>
                    <tr>
                    	 <td><input name="collegename2" type="text" id="collegename2" size="100" maxlength="100" /></td>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr> 
                        <td width="20%">Graduation Date:</td>
                        <td width="80%">Degree</td>
                    </tr>
                    <tr>
                    	<td><input name="graduationdate2" type="text" id="graduationdate2" size="10" maxlength="10" />&nbsp;(mm/dd/yyyy)</td>
                        <td><input name="degree2" type="text" id="degree2" size="50" maxlength="50"/></td>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr> 
                        <td width="40%">Major:</td>
                        <td width="20%"></td>
                        <td width="40%"></td>
                    </tr>
                    <tr>
                    	<td><input name="major2" type="text" id="major2" size="40" maxlength="40" /></td>
                    </tr>
                    <tr>
                    	<td>City</td>
                        <td>State/Province:</td>
                        <td>Country:</td>
                    </tr>
                    <tr>
                    	<td><input name="collegecity2" type="text" id="collegecity2" size="40" maxlength="40"/></td>
                        <td><input name="colloegestate2" type="text" id="collegestate2" size="20" maxlength="20" /></td>
                        <td><input name="collegecountry2" type="text" id="collegecountry2" size="30" maxlength="30" /></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
                </table>
                <!-- End Education -->
                <!-- Start Employment History -->
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td><strong>Employment History</strong></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                    <tr>
                    	<td>Please indicate your last employer and a facility in which you worked as a staff employee.</td>
                    </tr>
                    <tr>
                    	<td>May we contact your present employer? Yes: <input type="radio" name="contact" value="yes" id="contact" checked="checked"> No: <input type="radio" name="contact" value="no" id="contact"></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>                        
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td><strong>Most Recent Employer</strong></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
                <table width="70%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="40%">*Facility/Employer Name:</td>
                        <td width="30%">*Country</td>
                    </tr>
                    <tr>
                    	<td><input name="employername" type="text" id="employername" size="40" maxlength="40" class="reqd"/></td>
                        <td><input name="employercountry" type="text" id="employercountry" size="30" maxlength="30" class="reqd"/></td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="40%">*City:</td>
                        <td width="30%">*State/Province:</td>
                        <td width="20%">*Zip code/Postal code:</td>
                   </tr>
                   <tr>
                   		<td><input name="employercity" type="text" id="employercity" size="40" maxlength="40" class="reqd"/></td>
                        <td><input name="statename" type="text" id="statename" size="30" maxlength="30" class="reqd"/></td>
                        <td><input name="employerzip" type="text" id="employerzip" size="5" maxlength="5" class="reqd"/></td>
                   </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td>*Current Employer? Yes: <input type="radio" name="currentemployer" value="yes" id="currentemployer" > No: <input type="radio" name="currentemployer" value="no" id="currentemployer"></td>
                    </tr>
                </table>
                <table>
                	<tr>
                    	<td>Dates employed:</td>
                    </tr>
                </table>
                <table width="70%" border="0" cellspacing="" cellpadding="3">
                <tr>
                	<td width="35%">*From: <input name="datefrom" type="text" id="datefrom" size="10" maxlength="10" class="reqd"/>&nbsp;(mm/dd/yyyy)</td>
                    <td width="35%">*To: <input name="dateto" type="text" id="dateto" size="10" maxlength="10" class="reqd"/>&nbsp;(mm/dd/yyyy)</td>
                </tr>
                </table>
                <table>
                	<tr>
                    	<td>Reason for leaving: <input name="reason" type="text" id="reason" size="70" maxlength="70" class="reqd" /></td>
                    </tr>
                </table>
                <table width="100%" boarder="0" cellpadding="3" cellspacing="">
                	<tr>
                    	<td>&nbsp;</td>
                    </tr>
                	<tr>
                    	<td width="30%">*Position Held:</td>
                        <td width="40%">*Discipline:</td>
                        <td width="30%">If other, please specify:</td>
                    </tr>
                    <tr>
                    	<td><input name="position" type="text" id="position" size="30" maxlength="30" class="reqd" /></td>
                        <td><select name="employeddiscipline" id="employeddiscipline" class="reqd">
                            <option value="selectdiscipline" >Please select a discipline...</option>
                            <option value="RN" class="disciplineRN">RN</option>
                            <option value="CNA" class="disciplineCNA">CNA</option>
                            <option value="Other" class="disciplineOther">Other</option>
                            </select></td>
                        <td><input name="otherdiscipline" type="text" id="otherdiscipline" size="30" maxlength="30" /></td>
                   </tr>
                   <tr>
                   		<td>*Unit/Floor/Dept:</td>
                        <td>*Specialty:</td>
                        <td>If other, please specify:</td>
                   </tr>
                   <tr>
                   		<td><input name="department" type="text" id="department" size="30" maxlength="30" class="reqd" /></td>
                        <td><select name="employedspecialty" id="employedspecialty" class="reqd">
                            <option value="selectspeclty">Please select a specialty...</option>
                            <option value="MS">M/S</option>
                            <option value="ICU">ICU</option>
                            <option value="ER">ER</option>
                            <option value="Psych">Psych</option>
                            <option value="OB">OB</option>
                            <option value="Tele">Tele</option>
                            <option value="Other">Other</option>
                            </select></td>
                       <td><input name="otherspecialty" type="text" id="otherspecialty" size="30" maxlength="30" /></td>
                    </tr> 
                    <tr>
                    	<td>*Supervisor's Name:</td>
                        <td>*Supervisor's Title:</td>
                        <td>*Supervisor's Phone:</td>
                    </tr>
                   	<tr>
                    	<td><input name="supervisorsname" type="text" id="supervisorsname" size="30" maxlength="30" class="reqd"/></td>
                        <td><input name="supervisorstitle" type="text" id="supervisorstitle" size="30" maxlength="30" class="reqd"/></td>
                        <td><input name="supervisorsnumber" type="text" id="supervisorsnumber" size="30" maxlength="30" class="reqd"/></td>
                	</tr>
                    <tr>
                    	<td>Other Supervisor:</td>
                        <td>Phone:</td>
                    </tr>
                    <tr>
                    	<td><input name="othersupervisor" type="text" id="othersupervisor" size="30" maxlength="30" /></td>   
                        <td><input name="otherphone" type="text" id="otherphone" size="30" maxlength="30" /></td>
                    </tr>
                    <tr>
                    	<td>*Travel Assignment</td>
                        <td>"Travel Company</td>
                    </tr>
                    <tr>
                    	<td>Yes: <input type="radio" name="travelassignment" value="yes" id="travelassignment" > No: <input type="radio" name="travelassignment" value="no" id="travelassignment"></td>
                        <td><input name="travelcompany" type="text" id="travelcompany" size="30" maxlength="30" /></td>
                    </tr>
                    <tr>
                    	<td>*Local staff agency:</td>
                        <td>Yes: <input type="radio" name="agency" value="yes" id="agency" > No: <input type="radio" name="agency" value="no" id="agency" checked="checked"></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
                 <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td><strong>Employed as Core Staff</strong></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
                <table width="70%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="40%">Facility/Employer Name:</td>
                        <td width="30%">Country</td>
                    </tr>
                    <tr>
                    	<td><input name="employername2" type="text" id="employername2" size="40" maxlength="40" /></td>
                        <td><input name="employercountry2" type="text" id="employercountry2" size="30" maxlength="30" /></td>
                    </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td width="40%">City:</td>
                        <td width="30%">State/Province:</td>
                        <td width="20%">Zip code/Postal code:</td>
                   </tr>
                   <tr>
                   		<td><input name="employercity2" type="text" id="employercity2" size="40" maxlength="40" /></td>
                        <td><input name="statename2" type="text" id="statename2" size="30" maxlength="30" /></td>
                        <td><input name="employerzip2" type="text" id="employerzip2" size="5" maxlength="5" /></td>
                   </tr>
                </table>
                <table width="100%" border="0" cellspacing="" cellpadding="3">
                	<tr>
                    	<td>Current Employer? Yes: <input type="radio" name="currentemployer2" value="yes" id="currentemployer2" > No: <input type="radio" name="currentemployer2" value="no" id="currentemployer2" checked="checked"></td>
                    </tr>
                </table>
                <table>
                	<tr>
                    	<td>Dates employed:</td>
                    </tr>
                </table>
                <table width="70%" border="0" cellspacing="" cellpadding="3">
                <tr>
                	<td width="35%">From: <input name="datefrom2" type="text" id="datefrom2" size="10" maxlength="10"/>&nbsp;(mm/dd/yyyy)</td>
                    <td width="35%">To: <input name="dateto2" type="text" id="dateto2" size="10" maxlength="10"/>&nbsp;(mm/dd/yyyy)</td>
                </tr>
                </table>
                <table>
                	<tr>
                    	<td>Reason for leaving: <input name="reason" type="text" id="reason" size="70" maxlength="70"/></td>
                    </tr>
                </table>
                <table width="100%" boarder="0" cellpadding="3" cellspacing="">
                	<tr>
                    	<td>&nbsp;</td>
                    </tr>
                	<tr>
                    	<td width="30%">Position Held:</td>
                        <td width="40%">Discipline:</td>
                        <td width="30%">If other, please specify:</td>
                    </tr>
                    <tr>
                    	<td><input name="position2" type="text" id="position2" size="30" maxlength="30" /></td>
                        <td><select name="employeddiscipline2" id="employeddiscipline2" class="reqd">
                            <option value="selectdiscipline" >Please select a discipline...</option>
                            <option value="RN" class="disciplineRN">RN</option>
                            <option value="CNA" class="disciplineCNA">CNA</option>
                            <option value="Other" class="disciplineOther">Other</option>
                            </select></td>
                        <td><input name="otherdiscipline2" type="text" id="otherdiscipline2" size="30" maxlength="30" /></td>
                   </tr>
                   <tr>
                   		<td>Unit/Floor/Dept:</td>
                        <td>Specialty:</td>
                        <td>If other, please specify:</td>
                   </tr>
                   <tr>
                   		<td><input name="department2" type="text" id="department2" size="30" maxlength="30" /></td>
                        <td><select name="employedspecialty2" id="employedspecialty2" class="reqd">
                            <option value="selectspeclty">Please select a specialty...</option>
                            <option value="MS">M/S</option>
                            <option value="ICU">ICU</option>
                            <option value="ER">ER</option>
                            <option value="Psych">Psych</option>
                            <option value="OB">OB</option>
                            <option value="Tele">Tele</option>
                            <option value="Other">Other</option>
                            </select></td>
                       <td><input name="otherspecialty2" type="text" id="otherspecialty2" size="30" maxlength="30" /></td>
                    </tr> 
                    <tr>
                    	<td>Supervisor's Name:</td>
                        <td>Supervisor's Title:</td>
                        <td>Supervisor's Phone:</td>
                    </tr>
                   	<tr>
                    	<td><input name="supervisorsname2" type="text" id="supervisorsname2" size="30" maxlength="30" /></td>
                        <td><input name="supervisorstitle2" type="text" id="supervisorstitle2" size="30" maxlength="30" /></td>
                        <td><input name="supervisorsnumber2" type="text" id="supervisorsnumber2" size="30" maxlength="30" /></td>
                	</tr>
                    <tr>
                    	<td>Other Supervisor:</td>
                        <td>Phone:</td>
                    </tr>
                    <tr>
                    	<td><input name="othersupervisor2" type="text" id="othersupervisor2" size="30" maxlength="30" /></td>   
                        <td><input name="otherphone2" type="text" id="otherphone2" size="30" maxlength="30" /></td>
                    </tr>
                    <tr>
                    	<td>Travel Assignment</td>
                        <td>Travel Company</td>
                    </tr>
                    <tr>
                    	<td>Yes: <input type="radio" name="travelassignment2" value="yes" id="travelassignment2" > No: <input type="radio" name="travelassignment2" value="no" id="travelassignment2" checked="checked"></td>
                        <td><input name="travelcompany2" type="text" id="travelcompany2" size="30" maxlength="30" /></td>
                    </tr>
                    <tr>
                    	<td>Local staff agency:</td>
                        <td>Yes: <input type="radio" name="agency2" value="yes" id="agency2" > No: <input type="radio" name="agency2" value="no" id="agency2" checked="checked"></td>
                    </tr>
                    <tr>
                    	<td>&nbsp;</td>
                    </tr>
                </table>
                <!-- End Employment History -->
                <!-- Start Agreement -->
                <table width="100%" boarder="0" cellpadding="3" cellspacing="">
                	<tr>
                    	<td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
                    </tr>
                    <tr>
                    	<td>I attest that I am the applicant and the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information my result in disqualification from the program, and may be a violation of state law(s) that could result in civil penalties. RN Resources is authorized to obtain information from my current and previous employers, and to release information in support of my application (application, references, background search results, etc.) to RN Resource's client institutions. RN Resources may also share information regarding applicant's employment with its affiliates and appropriate governmental or licensing entities; and send me employment opportunity-related information at fax numbers or email addresses that I provide. I understand that RN Resources, certain states and/or Client institutions may require criminal background checks, and I consent to such checks. Prior to conducting any background checks that qualify as consumer or investigative consumer reports, I will be provided, and will return, separate disclosure and acknowledgment forms as required by RN Resources.</td>
                   </tr>
                </table>
                <table>
                   <tr>
                		<td>&nbsp;</td>
                   </tr>
                   <tr>
                   		<td><input type="checkbox" name="agreement" value="yes" id="agreement" class="rqed"/><strong>* I agree with the above statements.</strong></td>
                        <td>*Date: <input name="agreementdate" type="text" id="agreementdate" size="10" maxlength="10" class="reqd" />&nbsp;(mm/dd/yyyy)</td>
                   </tr>
                                      
                <!-- End Agreement -->
                <!-- Start of submit button -->
                <table>
                <tr>
                	<td><input type="submit" value="Submit"  /> </td>
                </tr>
                </table>
                <!-- End submti button -->
            </table>
            
        </form>
  <!-- end #mainContent --></div>
  <div id="footer">
    <!--Footer jpg will display here.-->
    <p>Copyright © 2009-2010. RN Resources, LLC all rights reserved.</p>
  <!-- end #footer --></div>
<!-- end #container --></div>
</body>
</html>
 
PHP CODE I HAVE SO FAR: ( IT IS NOT COMPELETED I GOT STUCK ON THE DROP DOWN MENU)
----------
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<link rel="stylesheet" type="text/css" href="CSS/layout.css">
<title>RN Resources, LLC</title>
</head>
 
<body class="oneColFixCtrHdr">
 
<div id="container">
  <div id="header">
    <!--Header jpg will display here.-->
    <div id="navMenu">
    			<ul>
        			<li><a href="index.html" class="home"> </a></li>
                    <li><a href="faq.html" class="faq"> </a></li>
        			<li><a href="about.html" class="about"> </a></li>
    			</ul>
    <!-- end #navMenu --></div>
    <!-- end #header --></div>
  <div id="mainContent"> 
 <?php
        $subject= "Online Application";
		$last_name = $_POST['lastname'];
		$first_name = $_POST['firstname'];
		$middle_initial = $_POST['middlename'];
		$primary_phone = $_POST['primaryphone'];
		$secondary_phone = $_POST['secondaryphone'];
		
		
        $mail_from= $_POST['customer_mail'];
        $header="from: ".$_POST['name']." <".$_POST['mail_from'].">";
        
        $to="totaleeyou@totaleeyou.com";
        
        $send_contact=mail($to,$subject,$message,$header);
        
        if($send_contact) {
        echo "Your Application was recieved. If you have any further questions please call us.";
        }
        else {
        echo "An error has occured. Please call us for further assistance.";
        }
  ?>
 
  <!-- end #mainContent --></div>
  <div id="footer">
    <!--Footer jpg will display here.-->
    <p>Copyright © 2009-2010. RN Resources, LLC all rights reserved.</p>
  <!-- end #footer --></div>
<!-- end #container --></div>
</body>
</html>

           
         
	Title
1	PHP survey form
2	send a form info to email
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Assigning Select Tag value to PHP vairable

Asked by neonate928 in PHP Scripting Language

About this solution
