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Direktori : /proc/thread-self/root/home2/selectio/public_html/salemgovtitialumni.in/
Upload File :
Current File : //proc/thread-self/root/home2/selectio/public_html/salemgovtitialumni.in/alumni-form.php

<?php include 'header.php' ?>

<?php

if(isset($_POST['submit_form'])){
        try{
            
            $name=$_POST['name'];
            $father_name = $_POST['father_name'];
            $present_address = $_POST['present_address'];
            $permanent_address = $_POST['permanent_address'];
            $mobile=$_POST['mobile'];
    	    $email=$_POST['email'];
            $education = $_POST['education'];
            $profession = $_POST['profession'];
            $training = $_POST['training'];
            $trade = $_POST['trade'];
            $member_ship = $_POST['member_ship'];
            
            error_log($email);
            
            $to = "ajay9345ajay@gmail.com"; 
     $subject = " Membership Application Form";
     
    /*$message = "<b>This is HTML message.</b>";
     $message .= "<h1>This is headline.</h1>";*/
     
     //$header = "$email\r\n";
     $header ="";
     $header .= "Name : ".$name."\r\n";
     $header .= "Father's Name : ".$father_name."\r\n";
     $header .= "Present Address : ".$present_address."\r\n";
     $header .= "Permanent Address : ".$permanent_address."\r\n";
     $header .= "Phone/Mobile No : ".$mobile."\r\n";
     $header .= "Email : ".$email."\r\n";
     $header .= "Educational Qualification : ".$education."\r\n";
     $header .= "Profession Or Business : ".$profession."\r\n";
     $header .= "Training Period : ".$training."\r\n";
     $header .= "Trade : ".$trade."\r\n";
     $header .= "Type of Membership :".$member_ship."\r\n";
     
     $retval = mail ($to,$subject,$header);
     
     if( $retval == true ) {
         echo '<script>alert("Message Sended Successfully")</script>'; 
     }else{
                 echo '<script>alert("Message could not be sent...")</script>';
                 
     } 
            
    
  
             
        }catch(Exception $e){
            $error=$e;
        }   
    }

?> 


<!-- Page Banner Start -->
        <div class="section page-banner-section" style="background-image: url(assets/images/bg/page-banner.jpg);margin-top: 15%;min-height: 130px;">
            <div class="container">
                <div class="page-banner-wrap">
                    <div class="row">
                        <div class="col-lg-12">
                            <!-- Page Banner Content Start -->
                            <div class="page-banner text-center" style="margin-top: -8%;">
                                <h2 class="title" style="color: #f17a28;">Application Form</h2>
                                <ul class="breadcrumb justify-content-center">
                                    <li class="breadcrumb-item" style="color: #2e3092;"><a href="index.php">Home</a></li>
                                    <li class="breadcrumb-item active" aria-current="page" style="color: #2e3092;">Application Forms</li>
                                </ul>
                            </div>
                            <!-- Page Banner Content End -->
                        </div>
                    </div>
                </div>
            </div>
        </div>
<!-- Page Banner End -->

        <!-- Contact Start -->
        <div class="section contact-section section-padding" style="padding-top: 50px;">
            <div class="container">
                <div class="row">
                    <div class="col-lg-12">
                        <h2 style="color: #2e3092;text-align: center;">MEMBERSHIP FORM</h2>
                        <!-- Contact Form Wrap Start -->
                        <div class="contact-form-wrap">
                            <form action="" method="POST" id="application_form">
                                <div class="row">
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Name:</label>
                                            <input class="form-control" type="text" name="name" placeholder="Your Name" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Father's Name:</label>
                                            <input class="form-control" type="text" name="father_name" placeholder="Your Father's Name" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Present Address:</label>
                                             <textarea class="form-control" name="present_address" placeholder="Enter Present Address" required></textarea>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Permanent Address:</label>
                                             <textarea class="form-control" name="permanent_address" placeholder="Enter Permanent Address" required></textarea>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Phone/Mobile No:</label>
                                            <input class="form-control" type="tel" name="mobile" placeholder="Your Mobile No" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Email:</label>
                                            <input class="form-control" type="email" name="email" placeholder="Your Email" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Educational Qualification:</label>
                                            <input class="form-control" type="text" name="education" placeholder="Your Qualification" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Profession or Business:</label>
                                            <input class="form-control" type="text" name="profession" placeholder="Profession" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Training Period:</label>
                                            <input class="form-control" type="text" name="training" placeholder="Training Period" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="single-form">
                                            <label>Trade:</label>
                                            <input class="form-control" type="text" name="trade" placeholder="Your Trade" required>
                                        </div>
                                    </div>
                                    <div class="col-md-6" style="margin-top: 2%;">
                                        <h4>Types of Membership:</h4>
                                        <div class="single-form" style="display: flex;">
                                            
                                            
                                           <input type="radio" id="annual" name="member_ship" value="ANNUAL TRAINEE" required>
                                            <label for="annual" style="padding: 5px;margin-top: 2%;padding-right: 5%;">Annual Trainee</label>
                                            
                                            <input type="radio" id="life" name="member_ship" value="LIFE">
                                            <label for="life" style="padding: 5px;margin-top: 2%;padding-right: 7%;">Life</label>
                                            
                                            <input type="radio" id="Elite" name="member_ship" value="ELITE">
                                            <label for="Elite" style="padding: 5px;margin-top: 2%;">Elite</label>
                                        </div>
                                    </div>
                                    <div class="col-md-12" style="margin-top: 2%;">
                                        <h2 style="text-align: center;">Declaration</h2>
                                        <div class="single-form" style="display: flex;margin-top: 0px;">
                                            
                                            <input type="checkbox" id="condition" name="condition" value="Accept" required>
                                            <p for="" style="margin-top: 25px;margin-left: 1%;line-height: 25px;">
                                                I hereby declare that the above mentioned details
                                                are true and correct to the best of my knowledge. I accept the all terms & conditions of <br> 
                                                <span style="color: #f17d2d;font-weight: 800;">SALEM GOVT. I.TI. ALUMNI ASSOCIATION</span> at time to time. 

                                            </p>
                                        </div>
                                    </div>
                                    <div class="col-md-12">
                                        <div class="form-btn">
                                            <button class="btn"  name="submit_form" type="submit">Send Message</button>
                                        </div>
                                    </div>
                                </div>
                            </form>
                        </div>
                        <!-- Contact Form Wrap End -->
                    </div>
                </div>
            </div>
        </div>
        <!-- Contact End -->

        <!-- Contact Map Start -->
       <!-- <div class="section contact-map-section">
            <div class="contact-map-wrap">
                <iframe id="gmap_canvas" src="https://www.google.com/maps/embed?pb=!1m18!1m12!1m3!1d3907.0526080363265!2d78.160305588855!3d11.690684200000014!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x3babf1071ccac523%3A0x1419eb7ced5d97ae!2sGovernment%20Industrial%20Training%20Institute!5e0!3m2!1sen!2sin!4v1695996873885!5m2!1sen!2sin" style="border:0;" allowfullscreen="" loading="lazy" referrerpolicy="no-referrer-when-downgrade"></iframe>
            </div>
        </div>-->
        <!-- Contact Map End -->



<?php include 'footer.php' ?>

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