Enroll Online - The Benefits My Way Program

function validate() { var x=0; var msg=""; if(document.forms.form1.comp_legal_name.value==""){ x=1; msg= msg+"please enter the Company Name\n"; } if(document.forms.form1.address_st.value==""){ x=1; msg= msg+"please enter the Street address\n"; } if(document.forms.form1.address_city.value==""){ x=1; msg= msg+"please enter the City\n"; } if(document.forms.form1.address_prov.value==""){ x=1; msg= msg+"please enter the Province\n"; } if(document.forms.form1.address_pc.value==""){ x=1; msg= msg+"please enter the Postal Code\n"; } if(document.forms.form1.phone_ac.value==""){ x=1; msg= msg+"please enter the correct area code for phone number\n"; } if(document.forms.form1.phone.value==""){ x=1; msg= msg+"please enter the correct phone number\n"; } if(document.forms.form1.email.value==""){ x=1; msg= msg+"please enter the Email address\n"; } if(document.forms.form1.contact_fname.value==""){ x=1; msg= msg+"please enter the Contact person First Name\n"; } if(document.forms.form1.contact_lname.value==""){ x=1; msg= msg+"please enter the Contact person Last Name\n"; } if(document.forms.form1.ref.value==""){ x=1; msg= msg+"please select How you heard about us \n"; } if(x==0) { document.forms.form1.submit(); } else { alert(msg); } } '; $todayis = date("l, F j, Y, g:i a"); if (isset($_GET['step']) && $_GET['step']==1) { if (md5($_POST['code']) != $_SESSION['__img_code__']) { $_GET['step'] = ''; print "

Wrong Validation code, Please Try again!

"; } } // STEP 1 if (!isset($_GET['step']) || $_GET['step'] == '') { echo '

STEP 1: Your Company Information

Welcome to CustomCare online registration. Please complete the following form providing your company details for The Benefits My Way Program.

NOTE: The address you enter below must match your credit card registered address otherwise your credit card will be declined.

If you have difficulties please do not hesitate to call us for assistance.

* indicates mandatory field

Registration Fee

$295.00 CAD + Tax
*

MAILING ADDRESS

* *
*
()
*

* Please provide full name or company
Please enter the validation code.

'; } // STEP 2 if(isset($_GET['step']) && $_GET['step']==1) { $order_id=time(); $message= ' There has been the following new registration. Order id: '.$order_id.' -------------------------------------------------------------------------------- Company Legal Name: '.$_REQUEST['comp_legal_name'].' Street Address: '.$_REQUEST['address_st'].' City: '.$_REQUEST['address_city'].' Province: '.$_REQUEST['address_prov'].' Postal Code: '.$_REQUEST['address_pc'].' Phone Number: '.$_REQUEST['phone_ac'].' '.$_REQUEST['phone'].' Email Address: '.$_REQUEST['email'].' Contact Person (first, last): '.$_REQUEST['contact_fname'].' '.$_REQUEST['contact_lname'].' How did you hear about us?: '.$_REQUEST['ref'].' If an advisor/client, who?: '.$_REQUEST['ref_text'].' Saw a voucher? Enter #: '.$_REQUEST['voucher'].' Type of Business: '; if($_REQUEST['sole_proprietor']==0) { $message=$message.'Incorporated/Ltd'; } else { $message=$message.'Sole Proprietor'; } $message=$message.' Additional Information: '.$_REQUEST['notes']; $to = 'admin@customcare.ca'; $headers = 'From: CustomCare Online ' . "\r\n" . 'Reply-To: CustomCare Online ' . "\r\n" . 'X-Mailer: PHP/' . phpversion(); $subject="New Client Registered ('.$order_id.')"; mail($to, $subject, $message, $headers); $price=295.00; $discount=false; if($_REQUEST['voucher']=='NH123' || $_REQUEST['voucher']=='FIREFIGHTER' || $_REQUEST['voucher']=='CMC123' || $_REQUEST['voucher']=='RW123' || $_REQUEST['voucher']=='ATC123' || $_REQUEST['voucher']=='CB123' || $_REQUEST['voucher']=='WHO123') { $price=$price-($price*0.2); $discount=true; } if($_REQUEST['voucher']=='UN123' || $_REQUEST['voucher']=='200566') { $price=$price-100; $discount=true; } if($_REQUEST['voucher']=='SAVE50') { $price=$price-50; $discount=true; } if($_REQUEST['voucher']=='ARI602') { $price=$price-95; $discount=true; } if($_REQUEST['voucher']=='GPCC2') { $price=0; $discount=true; } if($_REQUEST['voucher']=='CPCA1') { $price=$price-50; $discount=true; } $tax=0; if($_REQUEST['address_prov']=='AB' || $_REQUEST['address_prov']=='SK' || $_REQUEST['address_prov']=='MB' || $_REQUEST['address_prov']=='NT' || $_REQUEST['address_prov']=='YK') { $tax=$price*0.05; $taxpercentage=' 5% GST '; } if($_REQUEST['address_prov']=='BC') { $tax=$price*0.05; $taxpercentage=' 5% GST '; } if($_REQUEST['address_prov']=='NB' || $_REQUEST['address_prov']=='ON' || $_REQUEST['address_prov']=='NF') { $tax=$price*0.13; $taxpercentage=' 13% HST '; } if($_REQUEST['address_prov']=='PE') { $tax=$price*0.14; $taxpercentage=' 14% HST '; } if($_REQUEST['address_prov']=='NS') { $tax=$price*0.15; $taxpercentage=' 15% HST '; } $pricetax=$price+$tax; $query_string = 'comp_legal_name='.$_REQUEST['comp_legal_name']; $query_string .= '&address_st='.$_REQUEST['address_st'].'&address_city='.$_REQUEST['address_city'].'&address_prov='; $query_string .= $_REQUEST['address_prov'].'&address_pc='.$_REQUEST['address_pc'].'&phone_ac='.$_REQUEST['phone_ac']; $query_string .= '&phone='.$_REQUEST['phone']; $query_string .= '&contact_fname='.$_REQUEST['contact_fname'].'&contact_lname='.$_REQUEST['contact_lname'].'&ref='.$_REQUEST['ref'].'&ref_text='.$_REQUEST['ref_text'].'&voucher='.$_REQUEST['voucher']; echo '

STEP 2: Registration Fee

You are almost done...

To complete the registration process please provide your payment details.

* indicates mandatory field

'.(isset($_REQUEST['error']) ? $_REQUEST['error'] : '').'
Registration Fee $'.$pricetax.' CAD ($'.$price.' + '.$taxpercentage.')
CustomCare Inc. GST# 87133 3530

*
*
*
Amount '; if($discount==true) { echo '$'.$pricetax.' * Voucher Discount Applied!'; } else { echo '$'.$pricetax.''; } echo '

'; } ?>