ok
Mini Shell
<?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' ?>
Zerion Mini Shell 1.0