dprasad
asked on
Passing values to another page
I have a form that gets submitted to a seprate page, which then proceeds to send out an email. The form gets mailed just fine. however, there should be a credit card verfier form (on the second page) that sends the cc info to verisign. The credit card info fields do not show up at all.
Note that  the values are computed from a javascript like so:
<B><font size="+1"><font color="#FF0000">*</font>Me mbership Type</font></B></p>
 <table width="75%" border="0">
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value ="225 .00"; APP.DESCRI PTION.valu e="Ne w Membership Fee";Total();">
    New Member</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value ="150 .00"; APP.DESCRI PTION.valu e="AC TIVE MEMBER DUES";Total();">
           Active</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value ="75. 00";A PP.DESCRIP TION.value ="FIR ST YEAR (NEW MEMBER OR DUES)";Total();">
    1st Year in Practice</td>
  </tr>
  <tr>
 -------------------------- ---------- ---------- ---------- -
Here is the entire initial page:
domApplication.php
<!-- :Listing Info:: -->
<?php
// Get the libs and start making the page
require("$DOCUMENT_ROOT/in cludes/var .php");
@qdbconn();
@printHead();
?>
<SCRIPT TYPE="text/javascript" LANGUAGE="JavaScript">
<!--
function Total() {
  var tot = 0;
 Â
  tot += (1 * document.APP.memCost.value );
  tot += (1 * document.APP.don1.value);
  tot += (1 * document.APP.don2.value);
 Â
 document.APP.AMOUNT.value = tot + ".00";
 Â
}
function BuildDescription() {
  var desc = '';
      desc +=document.APP.desc1.value + " \n";
      desc +=document.APP.desc2.value + " \n";
  document.APP.contribution. value = desc;
}
var dataOK=false
function checkData()
{
if (document.APP.First.value. length <= 1) {
alert("First Name is a required field, please enter a value")
return false}
if (document.APP.Last.value.l ength <= 1) {
alert("Last Name is a required field, please enter a value")
return false}
if (document.APP.ADDRESS.valu e.length <= 1) {
alert("Address is a required field, please enter a value")
return false}
if (document.APP.CITY.value.l ength <= 1) {
alert("City is a required field, please enter a value")
return false}
if (document.APP.STATE.value. length <= 1) {
alert("State is a required field, please enter a value")
return false}
if (document.APP.PHONE.value. length <= 1) {
alert("Phone is a required field, please enter a value")
return false}
if (document.APP.EMAIL.value. length <= 1) {
alert("E-mail is a required field, please enter a value")
return false}
if (document.APP.value.length <= 1) {
alert("You must select a membership type to Continue")
return false}
if (document.APP.Degree.value .length <= 1) {
alert("You must enter your current Medical Degree")
return false}
if (document.APP.DOB.value.le ngth <= 1) {
alert("You must enter a Date Of Birth")
return false}
if (document.APP.OfficeAddres s.value.le ngth <= 1) {
alert("Please enter your current Office Address")
return false}
if (document.APP.City2.value. length <= 1) {
alert("Home Address City is required, Please enter your home city")
return false}
if (document.APP.St2.value.le ngth <= 1) {
alert("Home state is required, please enter your home state")
return false}
if (document.APP.MedSchool.va lue.length <= 1) {
alert("Medical School is required pleaser enter your Medical School")
return false}
if (document.APP.MedDegree.va lue.length <= 1) {
alert("Please enter the degree earned from Medical School")
return false}
if (document.APP.MedDegYr.val ue.length <= 1) {
alert("Please enter the year you graduated from Medical School")
return false}
if (document.APP.desc2.value != '') {
alert("By Clicking OK you are Verying payment with a Personal Credit Card")
return true}
if(!document.APP.Membershi pType[7].c hecked){
if (document.APP.MedLicYr.val ue.length <= 1) {
alert("Please enter the year you received your current medical Licence")
return false}
if (document.APP.MedLicSt.val ue.length <= 1) {
alert("Please enter the state in which your medical licence is valid")
return false}
}
//check whether or not user would like his or her email published in the Membership Directory
/*
 myOption = -1;
 for (i=0; i<APP.emailPub.length; i++) {
  if (APP.emailPub[i].checked) {
   myOption = i;
  }
 }
 if (myOption == -1) {
  alert("");
  return false;
 }
 else {
 Â
  return true;
 }
*/
return true
}
//-->
</SCRIPT>
<H3 CLASS="pgtitle" ALIGN="right">Application for Membership</H3>
<TABLE ALIGN="right">
<TR>
<TD ALIGN="center" CLASS="pgtitle"><B CLASS="sm">Introduction<BR >
to AACE</B></TD>
</TR>
<TR>
<TD BGCOLOR="#C0C0C0" CLASS="sm">
• <A HREF="mission.php">Our Mission</A><BR>
• <A HREF="history.php">Our History</A><BR>
• <A HREF="join.php">Invitation to Join</A><BR>
• Membership Application<br>
• <A HREF="dues.php">Member Dues Renewal</A>
</TD>
</TR>
</TABLE>
<TABLE BORDER="2" CELLPADDING="5" CELLSPACING="0">
 <TR>
 <TD><EM CLASS="rclr"><font color="#FF0000">Please note that fields marked with an asterisk (*) are required in order for your Application to be processed.</font></EM></TD >
 </TR>
</TABLE>
<a href="https://digitalid.verisign.com/as2/bd9a5f97c2b571f0ac1804443fd0c7e2" target="new"><img src="https://www.verisign.com/images/seals/Secure-White98x102.gif" width="98" height="100" border="0"></a>
<form action="app_procDOM.php" method="post" name="APP" id="APP" onSubmit="return checkData()">
<input type="hidden" name="DESCRIPTION" value="">
<input type="hidden" name="don1" value="0">
<input type="hidden" name="don2" value="0">
<input type="hidden" name="desc1" value="">
<input type="hidden" name="desc2" value="">
<input type="hidden" name="contribution" value="">
<input type="hidden" name="memCost" value="0">
<p> </p>
<table>
<TH ALIGN="left" COLSPAN="2">General Information</TH> Â
<tr><td>First Name:<font color="#FF0000">*</font></ td><td><IN PUT TYPE="Text" CLASS="frm" NAME="First" Â SIZE="20"></td></tr>
<tr><td>Full Middle Name:</td><td><INPUT Type="Text" class="frm" name="Middle" size="20"></td></tr>
<tr><td>Last Name:<font color="#FF0000">*</font></ td><td><in put Type="text" class="frm" name="Last" size="20"></td></tr>
<tr><td>Degree:<font color="#FF0000">*</font></ td><td><IN PUT TYPE="Text" CLASS="frm" NAME="Degree" SIZE="4"></td></tr></table >
     Â
      <TABLE>
         <TR>
     <TD ALIGN="right">Date of Birth:<font color="#FF0000">*</font></ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="DOB" SIZE="8"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Sex:<font color="#FF0000">*</font></ TD>
     <TD><INPUT NAME="Sex" TYPE="radio" VALUE="M" CHECKED> Male <INPUT NAME="Sex" TYPE="radio" VALUE="F"> Female</TD>
    </TR>
    <TR>
     <TD ALIGN="right">SS#:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="SocialSecurityNo" SIZE="12"> Spouse: <INPUT TYPE="Text" CLASS="frm" NAME="Spouse" SIZE="12"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">E-mail:<font color="#FF0000">*</font></ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="EMAIL" SIZE="30"></TD>
    </TR>
           <tr>
                 <TD ALIGN="right">Would you like your E-mail address published in the AACE Membership Directory?<font color="#FF0000">*</font></ TD>
                 <TD><input type="radio" name="emailPub" value="Yes" checked>Yes<input type="radio" name="emailPub" value="No">No</TD>
           </tr>
    <TR>
     <TH ALIGN="left" COLSPAN="2">Contact Information</TH>
    </TR>
    <TR>
     <TD ALIGN="right">Office Address:<font color="#FF0000">*</font></ TD>
     <TD><TEXTAREA CLASS="frm" cOLS="35" ROWS="3" NAME="OfficeAddress" SIZE="30"></TEXTAREA></TD>
    </TR>
    <TR>
     <TD ALIGN="right">CITY:<font color="#FF0000">*</font></ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="CITY" SIZE="20"> STATE: <INPUT TYPE="Text" CLASS="frm" NAME="STATE" SIZE="3"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">ZIP:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="ZIP" SIZE="10"> COUNTRY:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="COUNTRY" SIZE="12"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Office Phone:<font color="#FF0000">*</font></ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="PHONE" SIZE="16"> Please DO NOT include a + or -.</TD>
    </TR>
    <TR>
     <TD ALIGN="right">Office FAX:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="FAX" SIZE="16"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Home Address:<font color="#FF0000">*</font></ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="ADDRESS" SIZE="30"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">CITY:<font color="#FF0000">*</font></ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="City2" SIZE="20"> STATE: <INPUT TYPE="Text" CLASS="frm" NAME="St2" SIZE="3"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">ZIP:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="ZIP2" SIZE="10"> COUNTRY:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="COUNTRY2" SIZE="12"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Home Phone:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="HomePh" SIZE="16"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Home FAX:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="HomeFax" SIZE="16"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     Preferred Mailing Address:<br>
     <INPUT TYPE="radio" name="PrefAddr" VALUE="Office" checked>Office<BR>
     <INPUT NAME="PrefAddr" TYPE="radio" VALUE="Home">Home<BR>
     </TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     Preferred Address for Directory Listing:<br>
     <INPUT TYPE="radio" name="PrefDirectory" VALUE="Office" checked>Office<BR>
     <INPUT NAME="PrefDirectory" TYPE="radio" VALUE="Home">Home<BR>
     </TD>
    </TR>           Â
    <TR>
     <TD COLSPAN="2"><BR>
     <B>Practice Information</B><BR>
     Does Your Practice Consist of More than 50% ?:<BR>
     <INPUT NAME="GenEndo" TYPE="checkbox" VALUE="Yes">General Endocrinology and Metabolism<BR>
     <INPUT NAME="Diabetes" TYPE="checkbox" VALUE="Yes">Diabetes<BR>
     <INPUT NAME="Surgical" TYPE="checkbox" VALUE="Yes">Surgical Endocrinology<BR>
     <INPUT NAME="Pediatric" TYPE="checkbox" VALUE="Yes">Pediatric Endocrinology<BR>
     <INPUT NAME="Reproductive" TYPE="checkbox" VALUE="Yes">Reproductive Endocrinology<BR>
     Other: <INPUT TYPE="Text" CLASS="frm" NAME="Other" SIZE="20"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     <INPUT TYPE="Text" CLASS="frm" NAME="ClinicalTime" SIZE="5"> <STRONG>%</STRONG> of Time Spent in Clinical Practice</TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     Type of Practice:<BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="MultiSpecialtyGroup ">Multi-Sp ecialty Group<BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="SingleSpecialtyGrou p">Single Specialty
     Group<BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Solo">Solo<BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Teaching">Teaching< BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Research">Research< BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Administration">Adm inistratio n<BR>
     Other: <INPUT TYPE="Text" CLASS="frm" NAME="OtherDescription" SIZE="20"></TD>
    </TR>
    <TR>
<TD COLSPAN="2"><p><A NAME="mem"></A><BR>
   <B><font size="+1"><font color="#FF0000">*</font>Me mbership Type</font></B></p>
 <table width="75%" border="0">
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value ="225 .00"; APP.DESCRI PTION.valu e="Ne w Membership Fee";Total();">
    New Member</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value ="150 .00"; APP.DESCRI PTION.valu e="AC TIVE MEMBER DUES";Total();">
           Active</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value ="75. 00";A PP.DESCRIP TION.value ="FIR ST YEAR (NEW MEMBER OR DUES)";Total();">
    1st Year in Practice</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="Administration">
    Associate (fellow-in-Training)</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" VALUE="APP.memCost.value=& quot;75.00 ";APP .DESCRIPTI ON.value=& quot;RETIR ED (NEW MEMBER OR DUES";Total();"">
    Retired</td>
  </tr>
 </table> Â
<bR>
</TD>
    </TR>
    <TR>
     <TH ALIGN="left" COLSPAN="2">Education</TH>
    </TR>
    <TR>
     <TD ALIGN="right">College:&nbs p; </ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="College" SIZE="12"> Degree: <INPUT TYPE="Text" CLASS="frm" NAME="Degree1" SIZE="2"> Yr: <INPUT TYPE="Text" CLASS="frm" NAME="Yr1" SIZE="2"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Med. School:<font color="#FF0000">*</font></ TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="MedSchool" SIZE="12"> Degree:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="MedDegree" SIZE="2"> Yr:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="MedDegYr" SIZE="2"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Internship:< /TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="Internship" SIZE="30"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Fellowship:< /TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="Fellowship" SIZE="12"> Yr: <INPUT TYPE="Text" CLASS="frm" NAME="FellowYr" SIZE="2"> Duration: <INPUT TYPE="Text" CLASS="frm" NAME="FellowDuration" SIZE="2"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">PostGraduate :</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="PostGrad" SIZE="30"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2">Present Medical School | University
     Affiliations | Appointments<BR>
     <TEXTAREA COLS="35" ROWS="10" NAME="AfiliationsAppointme nts" CLASS="frm"></TEXTAREA></T D>
    </TR>
    <TR>
     <TD COLSPAN="2">Medical Licensure<br>
     Year: <INPUT TYPE="Text" CLASS="frm" NAME="MedLicYr" SIZE="5"> STATE: <INPUT TYPE="Text" CLASS="frm" NAME="MedLicSt" SIZE="3"> Years This
     Location: <INPUT TYPE="Text" CLASS="frm" NAME="YearsThere" SIZE="3"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2">Primary Areas of Clinical Interest (List up to
     two)<BR>
     <INPUT TYPE="Text" CLASS="frm" NAME="PrimarySpec1" SIZE="10"> <INPUT TYPE="Text" CLASS="frm" NAME="PrimarySpec2" SIZE="10"><br>
     Secondary Areas of Clinical Interest (List up to three)<BR>
     <INPUT TYPE="Text" CLASS="frm" NAME="SecSpec1" SIZE="10"> <INPUT TYPE="Text" CLASS="frm" NAME="SecSpec2" SIZE="10"> <INPUT TYPE="Text" CLASS="frm" NAME="SecSpec3" SIZE="10"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><B>Board Certifications:</B><BR>(Pl ease send copies of any Board certifications to the address listed <A HREF="http://www.aace.com/contact.php" TARGET="_blank">here</A>)
     Board: <INPUT TYPE="Text" CLASS="frm" NAME="BdCert1" SIZE="15"> Year: <INPUT TYPE="Text" CLASS="frm" NAME="Cert1Date" SIZE="5"><br>
     Board: <INPUT TYPE="Text" CLASS="frm" NAME="BdCert2" SIZE="15"> Year: <INPUT TYPE="Text" CLASS="frm" NAME="Cert2Date" SIZE="5"><br>
     Board: <INPUT TYPE="Text" CLASS="frm" NAME="BdCert3" SIZE="15"> Year: <INPUT TYPE="Text" CLASS="frm" NAME="Cert3Date" SIZE="5"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><p><STRONG>Mem berships</ STRONG><br >
      <INPUT NAME="ASIM" TYPE="checkbox" VALUE="Yes">
      American Society of Internal Medicine<BR>
      <INPUT NAME="AMA" TYPE="checkbox" VALUE="Yes">
      American Medical Association<BR>
      <INPUT NAME="ACP" TYPE="checkbox" VALUE="Yes">
      American College of Physicians<BR>
      <INPUT NAME="TES" TYPE="checkbox" VALUE="Yes">
      The Endocrine Society<BR>
      <INPUT NAME="ADA" TYPE="checkbox" VALUE="Yes">
      American Diabetes Association<BR>
      <INPUT NAME="ATA" TYPE="checkbox" VALUE="Yes">
      American Thyroid Association<BR>
                 <input NAME="ISCD" TYPE="checkbox" VALUE="Yes">
International Society of Clinical Densiometry<br>
      Other:
       <INPUT TYPE="Text" CLASS="frm" NAME="MemOther" SIZE="40">
     </p></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><p><strong>Mem bership Categories</strong></p>
     <p><STRONG>Active Membership:</STRONG> Any person licensed to practice
      medicine in the United States and who is engaged in the treatment
      of patients with endocrine diseases, involved in research or educational
      activities relating to endocrine diseases and/or Diabetes Mellitus
      is eligible for membership.</p>
     <P><STRONG>Associate Membership:</STRONG> Those physicians who are
      enrolled in postgraduate training in endocrinology or Diabetes Mellitus
      and able to submit a letter from their Department Chair verifying
     eligibility for Associate Status.</P>
     <P><strong>First Year in Practice: </strong>Same as active membership
     and in first year of practice after completion of endocrinology fellowship
      program.</P></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><p> </p>
      <p><B>Please list any Medical Journals to which
     you Subscribe</B><BR>
     (one per line please):<BR>
     <TEXTAREA CLASS="frm" COLS="20" ROWS="15" NAME="Journals"></TEXTAREA >
      </p></TD>
    </TR>
</TABLE>
 <input type="hidden" name="form_subject" id="form_subject" value="AACE Membership Application">
<p><input type="submit" value="Submit Application" > <input type="reset" value="I want to start over"></P>
</FORM>
 Â
<?php
@printFoot();
?>
-------------------------- ---------- ---------- ---------- ---------- ---------- --------
This is the form on the 2nd page thats not showing up
app_procDOM.php
<form action="https://payflowlink.verisign.com/payflowlink.cfm" method="post" name="SYMPOSIA">
<input type="hidden" name="NAME" value="<?php echo($NAME);?>" >
<input type="hidden" name="ADDRESS" value="<?php echo($ADDRESS);?>" >
<input type="hidden" name="PHONE" value="<?php echo($PHONE);?>" >
<input type="hidden" name="CITY" value="<?php echo($CITY);?>" >
<input type="hidden" name="ZIP" value="<?php echo($ZIP);?>" >
<input type="hidden" name="STATE" value="<?php echo($STATE);?>" >
<input type="hidden" name="COUNTRY" value="<?php echo($COUNTRY);?>" >
<input type="hidden" name="EMAIL" value="<?php echo($EMAIL);?>" ><br><br>
<input type="hidden" name="LOGIN" value="aaceaace"><input type="hidden" name="TYPE" value="S">
<input type="hidden" name="AMOUNT" value="<?php echo($AMOUNT);?>"><input type="hidden" name="DESCRIPTION" value="<?php echo($DESCRIPTION);?>">
<?php
// decide whether or not to show payflow button
if($AMOUNT >Â 0)
{
print("<strong>Click the Complete Application Button to Finalize the Application and pay dues</strong>");
print("<input type=\"hidden\" name=\"PARTNER\" value=\"verisign\"><input type=\"submit\" value=\"Complete Application\"></form>");
}
else
{
print("</form>");
print("Application Complete Thank You");
}
?>
<?php
The "Application Complete Thank You" shows up.
TIA!
Dinesh
Note that  the values are computed from a javascript like so:
<B><font size="+1"><font color="#FF0000">*</font>Me
 <table width="75%" border="0">
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value
    New Member</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value
           Active</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value
    1st Year in Practice</td>
  </tr>
  <tr>
 --------------------------
Here is the entire initial page:
domApplication.php
<!-- :Listing Info:: -->
<?php
// Get the libs and start making the page
require("$DOCUMENT_ROOT/in
@qdbconn();
@printHead();
?>
<SCRIPT TYPE="text/javascript" LANGUAGE="JavaScript">
<!--
function Total() {
  var tot = 0;
 Â
  tot += (1 * document.APP.memCost.value
  tot += (1 * document.APP.don1.value);
  tot += (1 * document.APP.don2.value);
 Â
 document.APP.AMOUNT.value = tot + ".00";
 Â
}
function BuildDescription() {
  var desc = '';
      desc +=document.APP.desc1.value
      desc +=document.APP.desc2.value
  document.APP.contribution.
}
var dataOK=false
function checkData()
{
if (document.APP.First.value.
alert("First Name is a required field, please enter a value")
return false}
if (document.APP.Last.value.l
alert("Last Name is a required field, please enter a value")
return false}
if (document.APP.ADDRESS.valu
alert("Address is a required field, please enter a value")
return false}
if (document.APP.CITY.value.l
alert("City is a required field, please enter a value")
return false}
if (document.APP.STATE.value.
alert("State is a required field, please enter a value")
return false}
if (document.APP.PHONE.value.
alert("Phone is a required field, please enter a value")
return false}
if (document.APP.EMAIL.value.
alert("E-mail is a required field, please enter a value")
return false}
if (document.APP.value.length
alert("You must select a membership type to Continue")
return false}
if (document.APP.Degree.value
alert("You must enter your current Medical Degree")
return false}
if (document.APP.DOB.value.le
alert("You must enter a Date Of Birth")
return false}
if (document.APP.OfficeAddres
alert("Please enter your current Office Address")
return false}
if (document.APP.City2.value.
alert("Home Address City is required, Please enter your home city")
return false}
if (document.APP.St2.value.le
alert("Home state is required, please enter your home state")
return false}
if (document.APP.MedSchool.va
alert("Medical School is required pleaser enter your Medical School")
return false}
if (document.APP.MedDegree.va
alert("Please enter the degree earned from Medical School")
return false}
if (document.APP.MedDegYr.val
alert("Please enter the year you graduated from Medical School")
return false}
if (document.APP.desc2.value != '') {
alert("By Clicking OK you are Verying payment with a Personal Credit Card")
return true}
if(!document.APP.Membershi
if (document.APP.MedLicYr.val
alert("Please enter the year you received your current medical Licence")
return false}
if (document.APP.MedLicSt.val
alert("Please enter the state in which your medical licence is valid")
return false}
}
//check whether or not user would like his or her email published in the Membership Directory
/*
 myOption = -1;
 for (i=0; i<APP.emailPub.length; i++) {
  if (APP.emailPub[i].checked) {
   myOption = i;
  }
 }
 if (myOption == -1) {
  alert("");
  return false;
 }
 else {
 Â
  return true;
 }
*/
return true
}
//-->
</SCRIPT>
<H3 CLASS="pgtitle" ALIGN="right">Application for Membership</H3>
<TABLE ALIGN="right">
<TR>
<TD ALIGN="center" CLASS="pgtitle"><B CLASS="sm">Introduction<BR
to AACE</B></TD>
</TR>
<TR>
<TD BGCOLOR="#C0C0C0" CLASS="sm">
• <A HREF="mission.php">Our Mission</A><BR>
• <A HREF="history.php">Our History</A><BR>
• <A HREF="join.php">Invitation
• Membership Application<br>
• <A HREF="dues.php">Member Dues Renewal</A>
</TD>
</TR>
</TABLE>
<TABLE BORDER="2" CELLPADDING="5" CELLSPACING="0">
 <TR>
 <TD><EM CLASS="rclr"><font color="#FF0000">Please note that fields marked with an asterisk (*) are required in order for your Application to be processed.</font></EM></TD
 </TR>
</TABLE>
<a href="https://digitalid.verisign.com/as2/bd9a5f97c2b571f0ac1804443fd0c7e2" target="new"><img src="https://www.verisign.com/images/seals/Secure-White98x102.gif" width="98" height="100" border="0"></a>
<form action="app_procDOM.php" method="post" name="APP" id="APP" onSubmit="return checkData()">
<input type="hidden" name="DESCRIPTION" value="">
<input type="hidden" name="don1" value="0">
<input type="hidden" name="don2" value="0">
<input type="hidden" name="desc1" value="">
<input type="hidden" name="desc2" value="">
<input type="hidden" name="contribution" value="">
<input type="hidden" name="memCost" value="0">
<p> </p>
<table>
<TH ALIGN="left" COLSPAN="2">General Information</TH> Â
<tr><td>First Name:<font color="#FF0000">*</font></
<tr><td>Full Middle Name:</td><td><INPUT Type="Text" class="frm" name="Middle" size="20"></td></tr>
<tr><td>Last Name:<font color="#FF0000">*</font></
<tr><td>Degree:<font color="#FF0000">*</font></
     Â
      <TABLE>
         <TR>
     <TD ALIGN="right">Date of Birth:<font color="#FF0000">*</font></
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="DOB" SIZE="8"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Sex:<font color="#FF0000">*</font></
     <TD><INPUT NAME="Sex" TYPE="radio" VALUE="M" CHECKED> Male <INPUT NAME="Sex" TYPE="radio" VALUE="F"> Female</TD>
    </TR>
    <TR>
     <TD ALIGN="right">SS#:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="SocialSecurityNo" SIZE="12"> Spouse: <INPUT TYPE="Text" CLASS="frm" NAME="Spouse" SIZE="12"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">E-mail:<font
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="EMAIL" SIZE="30"></TD>
    </TR>
           <tr>
                 <TD ALIGN="right">Would you like your E-mail address published in the AACE Membership Directory?<font color="#FF0000">*</font></
                 <TD><input type="radio" name="emailPub" value="Yes" checked>Yes<input type="radio" name="emailPub" value="No">No</TD>
           </tr>
    <TR>
     <TH ALIGN="left" COLSPAN="2">Contact Information</TH>
    </TR>
    <TR>
     <TD ALIGN="right">Office Address:<font color="#FF0000">*</font></
     <TD><TEXTAREA CLASS="frm" cOLS="35" ROWS="3" NAME="OfficeAddress" SIZE="30"></TEXTAREA></TD>
    </TR>
    <TR>
     <TD ALIGN="right">CITY:<font color="#FF0000">*</font></
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="CITY" SIZE="20"> STATE: <INPUT TYPE="Text" CLASS="frm" NAME="STATE" SIZE="3"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">ZIP:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="ZIP" SIZE="10"> COUNTRY:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="COUNTRY" SIZE="12"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Office Phone:<font color="#FF0000">*</font></
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="PHONE" SIZE="16"> Please DO NOT include a + or -.</TD>
    </TR>
    <TR>
     <TD ALIGN="right">Office FAX:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="FAX" SIZE="16"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Home Address:<font color="#FF0000">*</font></
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="ADDRESS" SIZE="30"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">CITY:<font color="#FF0000">*</font></
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="City2" SIZE="20"> STATE: <INPUT TYPE="Text" CLASS="frm" NAME="St2" SIZE="3"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">ZIP:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="ZIP2" SIZE="10"> COUNTRY:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="COUNTRY2" SIZE="12"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Home Phone:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="HomePh" SIZE="16"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Home FAX:</TD>
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="HomeFax" SIZE="16"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     Preferred Mailing Address:<br>
     <INPUT TYPE="radio" name="PrefAddr" VALUE="Office" checked>Office<BR>
     <INPUT NAME="PrefAddr" TYPE="radio" VALUE="Home">Home<BR>
     </TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     Preferred Address for Directory Listing:<br>
     <INPUT TYPE="radio" name="PrefDirectory" VALUE="Office" checked>Office<BR>
     <INPUT NAME="PrefDirectory" TYPE="radio" VALUE="Home">Home<BR>
     </TD>
    </TR>           Â
    <TR>
     <TD COLSPAN="2"><BR>
     <B>Practice Information</B><BR>
     Does Your Practice Consist of More than 50% ?:<BR>
     <INPUT NAME="GenEndo" TYPE="checkbox" VALUE="Yes">General Endocrinology and Metabolism<BR>
     <INPUT NAME="Diabetes" TYPE="checkbox" VALUE="Yes">Diabetes<BR>
     <INPUT NAME="Surgical" TYPE="checkbox" VALUE="Yes">Surgical Endocrinology<BR>
     <INPUT NAME="Pediatric" TYPE="checkbox" VALUE="Yes">Pediatric Endocrinology<BR>
     <INPUT NAME="Reproductive" TYPE="checkbox" VALUE="Yes">Reproductive Endocrinology<BR>
     Other: <INPUT TYPE="Text" CLASS="frm" NAME="Other" SIZE="20"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     <INPUT TYPE="Text" CLASS="frm" NAME="ClinicalTime" SIZE="5"> <STRONG>%</STRONG> of Time Spent in Clinical Practice</TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><BR>
     Type of Practice:<BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="MultiSpecialtyGroup
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="SingleSpecialtyGrou
     Group<BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Solo">Solo<BR>
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Teaching">Teaching<
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Research">Research<
     <INPUT NAME="PracticeType" TYPE="radio" VALUE="Administration">Adm
     Other: <INPUT TYPE="Text" CLASS="frm" NAME="OtherDescription" SIZE="20"></TD>
    </TR>
    <TR>
<TD COLSPAN="2"><p><A NAME="mem"></A><BR>
   <B><font size="+1"><font color="#FF0000">*</font>Me
 <table width="75%" border="0">
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value
    New Member</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value
           Active</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="APP.memCost.value
    1st Year in Practice</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" onClick="Administration">
    Associate (fellow-in-Training)</td>
  </tr>
  <tr>
   <td><INPUT NAME="MembershipType" TYPE="radio" VALUE="APP.memCost.value=&
    Retired</td>
  </tr>
 </table> Â
<bR>
</TD>
    </TR>
    <TR>
     <TH ALIGN="left" COLSPAN="2">Education</TH>
    </TR>
    <TR>
     <TD ALIGN="right">College:&nbs
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="College" SIZE="12"> Degree: <INPUT TYPE="Text" CLASS="frm" NAME="Degree1" SIZE="2"> Yr: <INPUT TYPE="Text" CLASS="frm" NAME="Yr1" SIZE="2"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Med. School:<font color="#FF0000">*</font></
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="MedSchool" SIZE="12"> Degree:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="MedDegree" SIZE="2"> Yr:<font color="#FF0000">*</font> <INPUT TYPE="Text" CLASS="frm" NAME="MedDegYr" SIZE="2"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Internship:<
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="Internship" SIZE="30"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">Fellowship:<
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="Fellowship" SIZE="12"> Yr: <INPUT TYPE="Text" CLASS="frm" NAME="FellowYr" SIZE="2"> Duration: <INPUT TYPE="Text" CLASS="frm" NAME="FellowDuration" SIZE="2"></TD>
    </TR>
    <TR>
     <TD ALIGN="right">PostGraduate
     <TD><INPUT TYPE="Text" CLASS="frm" NAME="PostGrad" SIZE="30"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2">Present Medical School | University
     Affiliations | Appointments<BR>
     <TEXTAREA COLS="35" ROWS="10" NAME="AfiliationsAppointme
    </TR>
    <TR>
     <TD COLSPAN="2">Medical Licensure<br>
     Year: <INPUT TYPE="Text" CLASS="frm" NAME="MedLicYr" SIZE="5"> STATE: <INPUT TYPE="Text" CLASS="frm" NAME="MedLicSt" SIZE="3"> Years This
     Location: <INPUT TYPE="Text" CLASS="frm" NAME="YearsThere" SIZE="3"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2">Primary Areas of Clinical Interest (List up to
     two)<BR>
     <INPUT TYPE="Text" CLASS="frm" NAME="PrimarySpec1" SIZE="10"> <INPUT TYPE="Text" CLASS="frm" NAME="PrimarySpec2" SIZE="10"><br>
     Secondary Areas of Clinical Interest (List up to three)<BR>
     <INPUT TYPE="Text" CLASS="frm" NAME="SecSpec1" SIZE="10"> <INPUT TYPE="Text" CLASS="frm" NAME="SecSpec2" SIZE="10"> <INPUT TYPE="Text" CLASS="frm" NAME="SecSpec3" SIZE="10"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><B>Board Certifications:</B><BR>(Pl
     Board: <INPUT TYPE="Text" CLASS="frm" NAME="BdCert1" SIZE="15"> Year: <INPUT TYPE="Text" CLASS="frm" NAME="Cert1Date" SIZE="5"><br>
     Board: <INPUT TYPE="Text" CLASS="frm" NAME="BdCert2" SIZE="15"> Year: <INPUT TYPE="Text" CLASS="frm" NAME="Cert2Date" SIZE="5"><br>
     Board: <INPUT TYPE="Text" CLASS="frm" NAME="BdCert3" SIZE="15"> Year: <INPUT TYPE="Text" CLASS="frm" NAME="Cert3Date" SIZE="5"></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><p><STRONG>Mem
      <INPUT NAME="ASIM" TYPE="checkbox" VALUE="Yes">
      American Society of Internal Medicine<BR>
      <INPUT NAME="AMA" TYPE="checkbox" VALUE="Yes">
      American Medical Association<BR>
      <INPUT NAME="ACP" TYPE="checkbox" VALUE="Yes">
      American College of Physicians<BR>
      <INPUT NAME="TES" TYPE="checkbox" VALUE="Yes">
      The Endocrine Society<BR>
      <INPUT NAME="ADA" TYPE="checkbox" VALUE="Yes">
      American Diabetes Association<BR>
      <INPUT NAME="ATA" TYPE="checkbox" VALUE="Yes">
      American Thyroid Association<BR>
                 <input NAME="ISCD" TYPE="checkbox" VALUE="Yes">
International Society of Clinical Densiometry<br>
      Other:
       <INPUT TYPE="Text" CLASS="frm" NAME="MemOther" SIZE="40">
     </p></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><p><strong>Mem
     <p><STRONG>Active Membership:</STRONG> Any person licensed to practice
      medicine in the United States and who is engaged in the treatment
      of patients with endocrine diseases, involved in research or educational
      activities relating to endocrine diseases and/or Diabetes Mellitus
      is eligible for membership.</p>
     <P><STRONG>Associate Membership:</STRONG> Those physicians who are
      enrolled in postgraduate training in endocrinology or Diabetes Mellitus
      and able to submit a letter from their Department Chair verifying
     eligibility for Associate Status.</P>
     <P><strong>First Year in Practice: </strong>Same as active membership
     and in first year of practice after completion of endocrinology fellowship
      program.</P></TD>
    </TR>
    <TR>
     <TD COLSPAN="2"><p> </p>
      <p><B>Please list any Medical Journals to which
     you Subscribe</B><BR>
     (one per line please):<BR>
     <TEXTAREA CLASS="frm" COLS="20" ROWS="15" NAME="Journals"></TEXTAREA
      </p></TD>
    </TR>
</TABLE>
 <input type="hidden" name="form_subject" id="form_subject" value="AACE Membership Application">
<p><input type="submit" value="Submit Application" > <input type="reset" value="I want to start over"></P>
</FORM>
 Â
<?php
@printFoot();
?>
--------------------------
This is the form on the 2nd page thats not showing up
app_procDOM.php
<form action="https://payflowlink.verisign.com/payflowlink.cfm" method="post" name="SYMPOSIA">
<input type="hidden" name="NAME" value="<?php echo($NAME);?>" >
<input type="hidden" name="ADDRESS" value="<?php echo($ADDRESS);?>" >
<input type="hidden" name="PHONE" value="<?php echo($PHONE);?>" >
<input type="hidden" name="CITY" value="<?php echo($CITY);?>" >
<input type="hidden" name="ZIP" value="<?php echo($ZIP);?>" >
<input type="hidden" name="STATE" value="<?php echo($STATE);?>" >
<input type="hidden" name="COUNTRY" value="<?php echo($COUNTRY);?>" >
<input type="hidden" name="EMAIL" value="<?php echo($EMAIL);?>" ><br><br>
<input type="hidden" name="LOGIN" value="aaceaace"><input type="hidden" name="TYPE" value="S">
<input type="hidden" name="AMOUNT" value="<?php echo($AMOUNT);?>"><input type="hidden" name="DESCRIPTION" value="<?php echo($DESCRIPTION);?>">
<?php
// decide whether or not to show payflow button
if($AMOUNT >Â 0)
{
print("<strong>Click the Complete Application Button to Finalize the Application and pay dues</strong>");
print("<input type=\"hidden\" name=\"PARTNER\" value=\"verisign\"><input type=\"submit\" value=\"Complete Application\"></form>");
}
else
{
print("</form>");
print("Application Complete Thank You");
}
?>
<?php
The "Application Complete Thank You" shows up.
TIA!
Dinesh
ASKER CERTIFIED SOLUTION
membership
This solution is only available to members.
To access this solution, you must be a member of Experts Exchange.
ASKER
thanks
dinesh