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Direktori : /proc/thread-self/root/proc/self/root/home2/selectio/www/salemgovtitialumni.in/ |
Current File : //proc/thread-self/root/proc/self/root/home2/selectio/www/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' ?>