Online Application Form!?

BuCki · September 12, 2009

<?php
mail("youremail@hotmail.com", "test email", "Just a test");
?>

I tried that and didnt receive the email.

Hmmmm probably the mail capability was removed, cos I know it was there before.

Damnnn

is there a script that can show if the email is turned off?!

DEVILofDARKNESS · September 12, 2009

yeah

<?php

phpinfo();

?>

and searsh for mail

It can be turned off.

BuCki · September 12, 2009

Ok guys... I got to go to my Football Training, so I catch up later.

Thanks for help

<input type="radio" maybe this will not let to choose multiple answers!

BuCki · September 12, 2009

sendmail_from no value no value

sendmail_path /usr/sbin/sendmail -t -i /usr/sbin/sendmail -t -i

thats what I see for mail!

DEVILofDARKNESS · September 12, 2009

Radio buttons only send one value can't send more

and try this and you will see if it is enabled or not:

<?php

$to = "email@example.com";
$header = "From: {$to}";
$subject = "Hi!";
$body = "Hi,\n\nHow are you?";
if (mail($to, $subject, $body, $header)) {
echo("<p>Message successfully sent!</p>");
} else {
echo("<p>Message delivery failed...</p>");
}


?>

BuCki · September 12, 2009

Yooo I am back from the Football match and we won

Anyway, I tried the above script and did not receive email.

BuCki · September 12, 2009

UPDATE:

I just tested the script on the x10hosting and it worked.

So what I am going to do is,... try my script and see what result I get

and get back to u for help etc.

Thanks guys

BuCki · September 12, 2009

Ok guys... please find the preview of the application form, which I am trying to make work.

Copy paste it into a (dreamweaver file) and you understand what I mean..

<form action="feedout.php" method="post">



<?php

$ipi = getenv("REMOTE_ADDR");

$httprefi = getenv ("HTTP_REFERER");

$httpagenti = getenv ("HTTP_USER_AGENT");

?>

<input type="hidden" name="ip" value="<?php echo $ipi ?>" />

<input type="hidden" name="httpref" value="<?php echo $httprefi ?>" />

<input type="hidden" name="httpagent" value="<?php echo $httpagenti ?>" />

<h2 align="center">Feedback Form</h2>

<p>

<p>Firstly, can I confirm your ethnic origin? </p>

<table width="601" border="1">

<tr>

<td colspan="2">WHITE</td>

<td width="12" rowspan="10"> </td>

<td colspan="2">Black / Black British </td>

</tr>

<tr>

<td width="168">British</td>

<td width="126"><input type="checkbox" name="British" value="y" /></td>

<td width="135">African</td>

<td width="126"><input type="checkbox" name="African" value="y" /></td>

</tr>

<tr>

<td>Irish</td>

<td><input type="checkbox" name="Irish" value="y" /></td>

<td>Caribbean</td>

<td><input type="checkbox" name="Caribbean" value="y" /></td>

</tr>

<tr>

<td>Gypsy & Roma </td>

<td><input type="checkbox" name="GypsyRoma" value="y" /></td>

<td>Somalian</td>

<td><input type="checkbox" name="Somalian" value="y" /></td>

</tr>

<tr>

<td>Eastern Europe </td>

<td><input type="text" name="EasternEurope" size="20" /></td>

<td>Other Black </td>

<td><input type="text" name="OtherBlack" size="20" /></td>

</tr>

<tr>

<td> </td>

<td> </td>

<td> </td>

<td> </td>

</tr>

<tr>

<td colspan="2">MIXED</td>

<td colspan="2">Other Ethnic Group</td>

</tr>

<tr>

<td>Asian & Black</td>

<td><input type="checkbox" name="AsianBlack" value="y" /></td>

<td>Afghani</td>

<td><input type="checkbox" name="Afghani" value="y" /></td>

</tr>

<tr>

<td>White & Asian</td>

<td><input type="checkbox" name="WhiteAsian" value="y" /></td>

<td>Arab – Iraqi</td>

<td><input type="checkbox" name="ArabIraqi" value="y" /></td>

</tr>

<tr>

<td>White & Black African</td>

<td><input type="checkbox" name="WhiteBlackAfrican" value="y" /></td>

<td>Arab – Saudi</td>

<td><input type="checkbox" name="ArabSaudi" value="y" /></td>

</tr>

<tr>

<td>White & Black Caribbean</td>

<td><input type="checkbox" name="WhiteBlackCaribbean" value="y" /></td>

<td> </td>

<td>Arab-Yemeni</td>

<td><input type="checkbox" name="ArabYemeni" value="y" /></td>

</tr>

<tr>

<td>Other Mixed </td>

<td><input type="text" name="OtherMixed" size="20" /></td>

<td> </td>

<td>Chinese</td>

<td><input type="checkbox" name="Chinese" value="y" /></td>

</tr>

<tr>

<td> </td>

<td> </td>

<td> </td>

<td>Iranian</td>

<td><input type="checkbox" name="Iranian" value="y" /></td>

</tr>

<tr>

<td colspan="2">Asian / Asian British </td>

<td> </td>

<td>Korean</td>

<td><input type="checkbox" name="Korean" value="y" /></td>

</tr>

<tr>

<td width="168">Indian</td>

<td width="126"><input type="checkbox" name="Indian" value="y" /></td>

<td> </td>

<td>Kurdish</td>

<td><input type="checkbox" name="Kurdish" value="y" /></td>

</tr>

<tr>

<td>Pakistani</td>

<td><input type="checkbox" name="Pakistani" value="y" /></td>

<td> </td>

<td>South American</td>

<td><input type="checkbox" name="SouthAmerican" value="y" /></td>

</tr>

<tr>

<td>Bangladeshi</td>

<td><input type="checkbox" name="Bangladeshi" value="y" /></td>

<td> </td>

<td>Vietnamese</td>

<td><input type="checkbox" name="Vietnamese" value="y" /></td>

</tr>

<tr>

<td>Gurjerati</td>

<td><input type="checkbox" name="Gurjerati" value="y" /></td>

<td> </td>

<td>Other Ethnic </td>

<td><input type="text" name="OtherEthnic" size="20" /></td>

</tr>

<tr>

<td>Kashmiri</td>

<td><input type="checkbox" name="Kashmiri" value="y" /></td>

<td> </td>

<td colspan="2" rowspan="4"> </td>

</tr>

<tr>

<td>East African Asian </td>

<td><input type="checkbox" name="EastAfricanAsian" value="y" /></td>

<td> </td>

</tr>

<tr>

<td>Siri Lankan </td>

<td><input type="checkbox" name="SiriLankan" value="y" /></td>

<td> </td>

</tr>

<tr>

<td>Other Asian </td>

<td><input type="text" name="OtherAsian" size="20" /></td>

<td> </td>

</tr>

</table>

<p>

1) How satisfied would you say you are with your local area as a place to live?</p>

<table width="445" border="1">

<tr>

<td width="110">Very satisfied </td>

<td width="22"><input type="checkbox" name="VerySatisfied" value="" /></td>

<td width="40"> </td>

<td width="210">Fairly dissatisfied </td>

<td width="34"><input type="checkbox" name="FairlyDissatisfied" value="" /></td>

</tr>

<tr>

<td>Fairly satisfied </td>

<td><input type="checkbox" name="FairlySatisfied" value="" /></td>

<td> </td>

<td>Very dissatisfied </td>

<td><input type="checkbox" name="VeryDissatisfied" value="" /></td>

</tr>

<tr>

<td> </td>

<td> </td>

<td> </td>

<td>Neither satisfied nor dissatisfied</td>

<td><input type="checkbox" name="NeitherSatisfiedDissatisfied" value="" /></td>

</tr>

</table>

<p>2) Which three things would most improve the quality of life in the area where you live?</p>

<p>

<label>

<textarea name="textarea" cols="80" rows="6">1

2

3</textarea>

</label>

</p>

<p>3) Which of the following NHS services have you used in the last 12 months and how good or poor were these services?</p>

<table width="639" border="1">

<tr>

<td width="93"> </td>

<td width="33"> </td>

<td width="20"> </td>

<td width="100"><div align="center">Very Good </div></td>

<td width="80"><div align="center">Good</div></td>

<td width="75"><div align="center">Neither</div></td>

<td width="86"> <div align="center">Poor </div></td>

<td width="100"><div align="center">Very Poor </div></td>

</tr>

<tr>

<td>GP Surgery</td>

<td><input type="checkbox" name="GPSurgery" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

<tr>

<td>Hospital</td>

<td><input type="checkbox" name="Hospital" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

<tr>

<td>Dentist</td>

<td><input type="checkbox" name="Dentist" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

<tr>

<td>NHS Direct </td>

<td><input type="checkbox" name="NHSDirect" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

</table>

<p>Now we would like to find out a little bit of information about you. This will help us to make sure the panel includes people from a range of backgrounds.</p>

<p>4) Specify your age: </p>

<table width="508" border="1">

<tr>

<td width="48">16-17</td>

<td width="20"><input type="checkbox" name="1617" value="" /></td>

<td width="25"> </td>

<td width="48">25-34</td>

<td width="20"><input type="checkbox" name="2534" value="" /></td>

<td width="25"> </td>

<td width="48">45-54</td>

<td width="20"><input type="checkbox" name="4554" value="" /></td>

<td width="25"> </td>

<td width="40">65+</td>

<td width="119"><input type="checkbox" name="65" value="" /></td>

</tr>

<tr>

<td>18-24</td>

<td><input type="checkbox" name="1824" value="" /></td>

<td> </td>

<td>35-44</td>

<td><input type="checkbox" name="3544" value="" /></td>

<td> </td>

<td>55-64</td>

<td><input type="checkbox" name="5564" value="" /></td>

<td> </td>

<td> </td>

<td> </td>

</tr>

</table>

<p>5) Specify your gender:</p>

<table width="200" border="1">

<tr>

<td width="42">Male</td>

<td width="22"><input type="checkbox" name="Male" value="" /></td>

<td width="25"> </td>

<td width="53">Female</td>

<td width="24"><input type="checkbox" name="Female" value="" /></td>

</tr>

</table>

<p>6) Specify your maritul status:</p>

<table width="355" border="1">

<tr>

<td width="69">Single</td>

<td width="28"><input type="checkbox" name="Single" value="" /></td>

<td width="38"> </td>

<td width="138">Living with parents </td>

<td width="48"><input type="checkbox" name="LivingWithParents" value="" /></td>

</tr>

<tr>

<td>Married</td>

<td><input type="checkbox" name="Married" value="" /></td>

<td> </td>

<td>Divorsed / Seperated </td>

<td><input type="checkbox" name="DivorsedSeperated" value="" /></td>

</tr>

</table>

<p>7) How many adults (over 16) and children (under 16) are there in your household? (please write numbers in the boxes provided)</p>

<table width="355" border="1">

<tr>

<td width="55">Adult</td>

<td width="49"><input type="text" name="Adult" size="5" /></td>

<td width="31"> </td>

<td width="75">Children</td>

<td width="111"><input type="Children" name="nameis" size="5" /></td>

</tr>

</table>

<p> How long have you lived in your neighbourhood? </p>

<p><input type="text" name="years" size="6" />

years</p>

<p>9) Are you</p>

<table width="600" border="1">

<tr>

<td width="200">Employed full time</td>

<td width="21"><input type="checkbox" name="EmployedFullTime" value="" /></td>

<td width="28"> </td>

<td width="206">Unemployed Seeking Work</td>

<td width="111"><input type="checkbox" name="UnemployedSeekingWork" value="" /></td>

</tr>

<tr>

<td>Employed Part Time</td>

<td><input type="checkbox" name="EmployedPartTime" value="" /></td>

<td> </td>

<td>Unemployed Not Seeking Work</td>

<td><input type="checkbox" name="UnemployedNotSeekingWork" value="" /></td>

</tr>

<tr>

<td>Self Employed</td>

<td><input type="checkbox" name="SelfEmployed" value="" /></td>

<td> </td>

<td>Full Time Education</td>

<td><input type="checkbox" name="FullTimeEducation" value="" /></td>

</tr>

<tr>

<td>Retired</td>

<td><input type="checkbox" name="Retired" value="" /></td>

<td> </td>

<td>Long Term Sick / Disabled</td>

<td><input type="checkbox" name="LongTermSick" value="" /></td>

</tr>

<tr>

<td>Looking After Home Or Family</td>

<td><input type="checkbox" name="LookingAfterHome" value="" /></td>

<td> </td>

<td>Other</td>

<td><input type="text" name="Other" size="18" /></td>

</tr>

</table>

<p>10) Do you have any disabilities or health problems, which limit your everyday activities in any way? </p>

<table width="207" border="1">

<tr>

<td width="43">Yes</td>

<td width="27"><input type="checkbox" name="Yes" value="" /></td>

<td width="28"> </td>

<td width="31">No</td>

<td width="44"><input type="checkbox" name="No" value="" /></td>

</tr>

</table>

<p>11) Please provide your name and address for correspondence : </p>

<p>

<label>

<textarea name="textarea2" cols="80" rows="8">Name:

Address:

Telephone/Mobile:</textarea>

</label>

</p>

<p>12) How would you prefer to be contacted about the panel : (choose one)</p>

<table width="600" border="1">

<tr>

<td width="50">Post</td>

<td width="20"><input type="checkbox" name="Post" value="" /></td>

<td width="40"> </td>

<td width="54">Email</td>

<td><input type="text" name="Email" size="35" /></td>

</tr>

</table>

<p>13) What is your first language?</p>

<table width="600" border="1">

<tr>

<td width="50">English</td>

<td width="20"><input name="English" type="checkbox" value="" /></td>

<td width="40"> </td>

<td width="54">Other</td>

<td><input name="OtherLanguages" type="text" size="35" /></td>

</tr>

</table>

<p>From time to time, you may be asked if you would like to take part in group discussions or focus groups.<br>

To help us tailor these offers to your interests, please tell us which of the following services you have used within the last 12 months? <br>

<br>

(Please tick as many as apply)</p>

<table width="599" border="1">

<tr>

<td width="151">Housing </td>

<td width="21"><input name="Housing" type="checkbox" value="" /></td>

<td width="30"> </td>

<td width="117">Art & Culture</td>

<td width="20"><input name="ArtCulture" type="checkbox" value="" /></td>

<td width="30"> </td>

<td width="158">Children & Young People</td>

<td width="20"><input name="ChildrenYoungPeople" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Education (up to 18yrs)</td>

<td><input name="EducationUpTo18" type="checkbox" value="" /></td>

<td> </td>

<td>Libraries</td>

<td><input name="Libraries" type="checkbox" value="" /></td>

<td> </td>

<td>Older People</td>

<td><input name="OlderPeople" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Adult Education </td>

<td><input name="AdultEducation" type="checkbox" value="" /></td>

<td> </td>

<td>Sport </td>

<td><input name="Sport" type="checkbox" value="" /></td>

<td> </td>

<td>Traffic </td>

<td><input name="Traffic" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Environmental Issues </td>

<td><input name="EnvironmentalIssues" type="checkbox" value="" /></td>

<td> </td>

<td>Public Transport</td>

<td><input name="PublicTransport" type="checkbox" value="" /></td>

<td> </td>

<td>Crime & Comm. Safety</td>

<td><input name="CrimeCommSafety" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Health</td>

<td><input name="Health" type="checkbox" value="" /></td>

<td> </td>

<td>Social Services </td>

<td><input name="Social Services" type="checkbox" value="" /></td>

<td> </td>

<td>Employment & Training</td>

<td><input name="EmploymentTraining" type="checkbox" value="" /></td>

</tr>

</table>

<p>And finally, the information supplied on this form will be stored electronically by BBEMI and Public Sector Organisations in Barnsley.<br>

Your details will only be used for the purposes of the BME Residents Panel and will NOT be passed on to any third party. <br>

<em> <input name="Agree" type="checkbox" value="" />

I agree to my information being used for this purpose. </em></p>

<p> </p>

<p align="center">

<input type="submit" value="Submit Feedback" />

</p>

</form>

When clicking submit button, the ticked boxes etc should be email with the result.

IThis is what I use:

<h3 align="center">Thanks for your Feedback </h3>


<?php

$ip = $_POST['ip'];

$httpagent = $_POST['httpagent'];

$httpref = $_POST['$httpref'];

$nameis = $_POST['nameis'];

$visitormail = $_POST['visitormail'];

$feedback = $_POST['feedback'];

$rating = $_POST['rating'];

$checkbox = $_POST['y'];

$emailvalidation = $_POST['emailvalidation'];

$British = $_POST['Brtish'];

$Irish= $_POST['Irish'];

$GypsyRoma = $_POST['GypsyRoma'];

$EasternEurope = $_POST['EasternEurope'];

$attn = $_POST['attn'];

if (eregi('http:', $feedback)) { die ("Do NOT try that! ! "); }

if((!$visitormail == "") && (!strstr($visitormail,"@") || !strstr($visitormail,".")))

{

echo "<h2>Use Back - Enter valid e-mail</h2>\n";

$tellem = "<h2>Feedback was NOT submitted</h2>\n";

}

if(empty($nameis) || empty($feedback) || empty($visitormail)) {

echo "<h2>Use Back - fill in all fields</h2>\n";

}

echo $tellem;

if ($emailvalidation == "y") {

$req1 = "Email format Validation \n" ;

}

if ($fieldvalidation == "y") {

$req2 = "Required Form Field Validation \n";

}

if ($British == "y") {

$q1 = "British \n";

}

if ($Irish == "y") {

$q2 = "Irish \n";

}

if ($GypsyRoma == "y") {

$q3 = "Gypsy and Roma \n";

}

if ($EasternEurope == "y") {

$q4 = "Eastern Europe \n";

}

$q = $q1 . $q2 . $q3 . $q4;

$todayis = date("l, F j, Y, g:i a") ;

$attn = $attn;

$subject = $attn;

$feedback = stripcslashes($feedback);

$message = " $todayis [EST] \n

Attention: $attn Rating: $rating $checkbox \n

From: $nameis ($visitormail)\n

Requested:

$req \n

Feedback: $feedback \n

Additional Info : IP = $ip \n

Browser = $httpagent \n

Referral = $httpref

";

$from = "From: $visitormail\r\n";

mail( "myemail@hotmail.co.uk", "Whatever", $message, $from );

$screenout = str_replace("\n", "<br/>", $message);

?>

<p align="center">

<?php echo $screenout ?>

</p>

However, I got no clue how t put all together.

BOTTOM LINE: if some1 can do the script based on the 1st quote:, I will send him some money via paypal, I live in UK AND I WOULD PAY AT LEAST £10.

Thanks

BuCki · September 12, 2009

Whoever can manage to do this... I pay him/her at least £10 - I promise.

Its an application form, which its results need to be send to my email.

Maybe someone, got the time and the kindness to help me out.

I know, you might say... look up on internet and google... BUT GUYS

something I got no clue with, I could end up looking up all week and stil be at the current position.

Som if someone thinks well ok I can do this for you then of course I pay you the money 100%

This is the form:

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">

<head>

<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />

<title>Untitled Document</title>

<style type="text/css">

*{ margin: 0px; padding: 0px; margin-left:5px; }*

body {

font: .75em "Trebuchet MS", Tahoma, Verdana, Arial, Helvetica, sans-serif;

line-height: 1.6em;

background: #fff;

color: #444;

}

.table { border:1px solid #DADADA; padding:5px;}

p { margin: 0 0 15px 0; }

h1 { margin: 20px 0 0; }

h2 { font: normal 1.6em "Trebuchet MS", Arial, Sans-Serif; margin: 0 0 12px; }

h3 a { font-size: 1em; }

</style>

</head>

<body>

<h2>Application Form</h2>

<p>

<p>Firstly, can I confirm your ethnic origin? </p>

<table width="601" class="table">

<tr>

<td colspan="2">WHITE</td>

<td width="12" rowspan="10"> </td>

<td colspan="2">Black / Black British </td>

</tr>

<tr>

<td width="168">British</td>

<td width="126"><input type="checkbox" name="British" value="y" /></td>

<td width="135">African</td>

<td width="126"><input type="checkbox" name="African" value="y" /></td>

</tr>

<tr>

<td>Irish</td>

<td><input type="checkbox" name="Irish" value="y" /></td>

<td>Caribbean</td>

<td><input type="checkbox" name="Caribbean" value="y" /></td>

</tr>

<tr>

<td>Gypsy & Roma </td>

<td><input type="checkbox" name="GypsyRoma" value="y" /></td>

<td>Somalian</td>

<td><input type="checkbox" name="Somalian" value="y" /></td>

</tr>

<tr>

<td>Eastern Europe </td>

<td><input type="text" name="EasternEurope" size="18" /></td>

<td>Other Black </td>

<td><input type="text" name="OtherBlack" size="18" /></td>

</tr>

<tr>

<td> </td>

<td> </td>

<td> </td>

<td> </td>

</tr>

<tr>

<td colspan="2">MIXED</td>

<td colspan="2">Other Ethnic Group</td>

</tr>

<tr>

<td>Asian & Black</td>

<td><input type="checkbox" name="AsianBlack" value="y" /></td>

<td>Afghani</td>

<td><input type="checkbox" name="Afghani" value="y" /></td>

</tr>

<tr>

<td>White & Asian</td>

<td><input type="checkbox" name="WhiteAsian" value="y" /></td>

<td>Arab – Iraqi</td>

<td><input type="checkbox" name="ArabIraqi" value="y" /></td>

</tr>

<tr>

<td>White & Black African</td>

<td><input type="checkbox" name="WhiteBlackAfrican" value="y" /></td>

<td>Arab – Saudi</td>

<td><input type="checkbox" name="ArabSaudi" value="y" /></td>

</tr>

<tr>

<td>White & Black Caribbean</td>

<td><input type="checkbox" name="WhiteBlackCaribbean" value="y" /></td>

<td> </td>

<td>Arab-Yemeni</td>

<td><input type="checkbox" name="ArabYemeni" value="y" /></td>

</tr>

<tr>

<td>Other Mixed </td>

<td><input type="text" name="OtherMixed" size="18" /></td>

<td> </td>

<td>Chinese</td>

<td><input type="checkbox" name="Chinese" value="y" /></td>

</tr>

<tr>

<td> </td>

<td> </td>

<td> </td>

<td>Iranian</td>

<td><input type="checkbox" name="Iranian" value="y" /></td>

</tr>

<tr>

<td colspan="2">Asian / Asian British </td>

<td> </td>

<td>Korean</td>

<td><input type="checkbox" name="Korean" value="y" /></td>

</tr>

<tr>

<td width="168">Indian</td>

<td width="126"><input type="checkbox" name="Indian" value="y" /></td>

<td> </td>

<td>Kurdish</td>

<td><input type="checkbox" name="Kurdish" value="y" /></td>

</tr>

<tr>

<td>Pakistani</td>

<td><input type="checkbox" name="Pakistani" value="y" /></td>

<td> </td>

<td>South American</td>

<td><input type="checkbox" name="SouthAmerican" value="y" /></td>

</tr>

<tr>

<td>Bangladeshi</td>

<td><input type="checkbox" name="Bangladeshi" value="y" /></td>

<td> </td>

<td>Vietnamese</td>

<td><input type="checkbox" name="Vietnamese" value="y" /></td>

</tr>

<tr>

<td>Gurjerati</td>

<td><input type="checkbox" name="Gurjerati" value="y" /></td>

<td> </td>

<td>Other Ethnic </td>

<td><input type="text" name="OtherEthnic" size="18" /></td>

</tr>

<tr>

<td>Kashmiri</td>

<td><input type="checkbox" name="Kashmiri" value="y" /></td>

<td> </td>

<td colspan="2" rowspan="4"> </td>

</tr>

<tr>

<td>East African Asian </td>

<td><input type="checkbox" name="EastAfricanAsian" value="y" /></td>

<td> </td>

</tr>

<tr>

<td>Siri Lankan </td>

<td><input type="checkbox" name="SiriLankan" value="y" /></td>

<td> </td>

</tr>

<tr>

<td>Other Asian </td>

<td><input type="text" name="OtherAsian" size="18" /></td>

<td> </td>

</tr>

</table>

<p> </p>

<p>1) How satisfied would you say you are with your local area as a place to live?</p>

<table width="445" border="0" class="table">

<tr>

<td width="110">Very satisfied </td>

<td width="22"><input type="checkbox" name="VerySatisfied" value="" /></td>

<td width="40"> </td>

<td width="210">Fairly dissatisfied </td>

<td width="34"><input type="checkbox" name="FairlyDissatisfied" value="" /></td>

</tr>

<tr>

<td>Fairly satisfied </td>

<td><input type="checkbox" name="FairlySatisfied" value="" /></td>

<td> </td>

<td>Very dissatisfied </td>

<td><input type="checkbox" name="VeryDissatisfied" value="" /></td>

</tr>

<tr>

<td> </td>

<td> </td>

<td> </td>

<td>Neither satisfied nor dissatisfied</td>

<td><input type="checkbox" name="NeitherSatisfiedDissatisfied" value="" /></td>

</tr>

</table>

<p> </p>

<p>2) Which three things would most improve the quality of life in the area where you live?</p>

<p>

<label>

<textarea name="textarea" cols="70" rows="6">1

2

3</textarea>

</label>

</p>

<p><br />

3) Which of the following NHS services have you used in the last 12 months and how good or poor were these services?</p>

<table width="639" border="0" class="table">

<tr>

<td width="93"> </td>

<td width="33"> </td>

<td width="20"> </td>

<td width="100"><div align="center">Very Good </div></td>

<td width="80"><div align="center">Good</div></td>

<td width="75"><div align="center">Neither</div></td>

<td width="86"> <div align="center">Poor </div></td>

<td width="100"><div align="center">Very Poor </div></td>

</tr>

<tr>

<td>GP Surgery</td>

<td><input type="checkbox" name="GPSurgery" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

<tr>

<td>Hospital</td>

<td><input type="checkbox" name="Hospital" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

<tr>

<td>Dentist</td>

<td><input type="checkbox" name="Dentist" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

<tr>

<td>NHS Direct </td>

<td><input type="checkbox" name="NHSDirect" value="" /></td>

<td> </td>

<td><div align="center"><input type="checkbox" name="VeryGood" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Good" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Neither" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="Poor" value="" /></div></td>

<td><div align="center"><input type="checkbox" name="VeryPoor" value="" /></div></td>

</tr>

</table>

<p> </p>

<p>Now we would like to find out a little bit of information about you. This will help us to make sure the panel includes people from a range of backgrounds.</p>

<p>4) Specify your age: </p>

<table width="508" border="0" class="table">

<tr>

<td width="48">16-17</td>

<td width="20"><input type="checkbox" name="1617" value="" /></td>

<td width="25"> </td>

<td width="48">25-34</td>

<td width="20"><input type="checkbox" name="2534" value="" /></td>

<td width="25"> </td>

<td width="48">45-54</td>

<td width="20"><input type="checkbox" name="4554" value="" /></td>

<td width="25"> </td>

<td width="40">65+</td>

<td width="119"><input type="checkbox" name="65" value="" /></td>

</tr>

<tr>

<td>18-24</td>

<td><input type="checkbox" name="1824" value="" /></td>

<td> </td>

<td>35-44</td>

<td><input type="checkbox" name="3544" value="" /></td>

<td> </td>

<td>55-64</td>

<td><input type="checkbox" name="5564" value="" /></td>

<td> </td>

<td> </td>

<td> </td>

</tr>

</table>

<p> </p>

<p>5) Specify your gender:</p>

<table width="200" border="0" class="table">

<tr>

<td width="42">Male</td>

<td width="22"><input type="checkbox" name="Male" value="" /></td>

<td width="25"> </td>

<td width="53">Female</td>

<td width="24"><input type="checkbox" name="Female" value="" /></td>

</tr>

</table>

<p> </p>

<p>6) Specify your maritul status:</p>

<table width="355" border="0" class="table">

<tr>

<td width="69">Single</td>

<td width="23"><input type="checkbox" name="Single" value="" /></td>

<td width="66"> </td>

<td width="138">Living with parents </td>

<td width="35"><input type="checkbox" name="LivingWithParents" value="" /></td>

</tr>

<tr>

<td>Married</td>

<td><input type="checkbox" name="Married" value="" /></td>

<td> </td>

<td>Divorsed / Seperated </td>

<td><input type="checkbox" name="DivorsedSeperated" value="" /></td>

</tr>

</table>

<p> </p>

<p>7) How many adults (over 16) and children (under 16) are there in your household? (please write numbers in the boxes provided)</p>

<table width="282" border="0" class="table">

<tr>

<td width="56">Adult</td>

<td width="48"><input type="text" name="Adult" size="5" /></td>

<td width="34"> </td>

<td width="78">Children</td>

<td width="42"><input type="Children" name="nameis" size="5" /></td>

</tr>

</table>

<p> </p>

<p> How long have you lived in your neighbourhood? </p>

<p><input type="text" name="years" size="6" />

years</p>

<p>9) Are you</p>

<table width="600" border="0" class="table">

<tr>

<td width="200">Employed full time</td>

<td width="21"><input type="checkbox" name="EmployedFullTime" value="" /></td>

<td width="28"> </td>

<td width="206">Unemployed Seeking Work</td>

<td width="111"><input type="checkbox" name="UnemployedSeekingWork" value="" /></td>

</tr>

<tr>

<td>Employed Part Time</td>

<td><input type="checkbox" name="EmployedPartTime" value="" /></td>

<td> </td>

<td>Unemployed Not Seeking Work</td>

<td><input type="checkbox" name="UnemployedNotSeekingWork" value="" /></td>

</tr>

<tr>

<td>Self Employed</td>

<td><input type="checkbox" name="SelfEmployed" value="" /></td>

<td> </td>

<td>Full Time Education</td>

<td><input type="checkbox" name="FullTimeEducation" value="" /></td>

</tr>

<tr>

<td>Retired</td>

<td><input type="checkbox" name="Retired" value="" /></td>

<td> </td>

<td>Long Term Sick / Disabled</td>

<td><input type="checkbox" name="LongTermSick" value="" /></td>

</tr>

<tr>

<td>Looking After Home Or Family</td>

<td><input type="checkbox" name="LookingAfterHome" value="" /></td>

<td> </td>

<td>Other</td>

<td><input type="text" name="Other" size="18" /></td>

</tr>

</table>

<p> </p>

<p>10) Do you have any disabilities or health problems, which limit your everyday activities in any way? </p>

<table width="207" border="0" class="table">

<tr>

<td width="40">Yes</td>

<td width="24"><input type="checkbox" name="Yes" value="" /></td>

<td width="47"> </td>

<td width="39">No</td>

<td width="23"><input type="checkbox" name="No" value="" /></td>

</tr>

</table>

<p> </p>

<p>11) Please provide your name and address for correspondence : </p>

<p>

<label>

<textarea name="textarea2" cols="80" rows="8">Name:

Address:

Telephone/Mobile:</textarea>

</label>

</p>

<p>12) How would you prefer to be contacted about the panel : (choose one)</p>

<table width="409" border="0" class="table">

<tr>

<td width="50">Post</td>

<td width="20"><input type="checkbox" name="Post" value="" /></td>

<td width="40"> </td>

<td width="54">Email</td>

<td><input type="text" name="Email" size="35" /></td>

</tr>

</table>

<p> </p>

<p>13) What is your first language?</p>

<table width="409" border="0" class="table">

<tr>

<td width="50">English</td>

<td width="20"><input name="English" type="checkbox" value="" /></td>

<td width="40"> </td>

<td width="54">Other</td>

<td><input name="OtherLanguages" type="text" size="35" /></td>

</tr>

</table>

<p> </p>

<p>From time to time, you may be asked if you would like to take part in group discussions or focus groups.<br>

To help us tailor these offers to your interests, please tell us which of the following services you have used within the last 12 months? <br>

<br>

(Please tick as many as apply)</p>

<table width="599" border="0" class="table">

<tr>

<td width="151">Housing </td>

<td width="21"><input name="Housing" type="checkbox" value="" /></td>

<td width="30"> </td>

<td width="117">Art & Culture</td>

<td width="20"><input name="ArtCulture" type="checkbox" value="" /></td>

<td width="30"> </td>

<td width="158">Children & Young People</td>

<td width="20"><input name="ChildrenYoungPeople" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Education (up to 18yrs)</td>

<td><input name="EducationUpTo18" type="checkbox" value="" /></td>

<td> </td>

<td>Libraries</td>

<td><input name="Libraries" type="checkbox" value="" /></td>

<td> </td>

<td>Older People</td>

<td><input name="OlderPeople" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Adult Education </td>

<td><input name="AdultEducation" type="checkbox" value="" /></td>

<td> </td>

<td>Sport </td>

<td><input name="Sport" type="checkbox" value="" /></td>

<td> </td>

<td>Traffic </td>

<td><input name="Traffic" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Environmental Issues </td>

<td><input name="EnvironmentalIssues" type="checkbox" value="" /></td>

<td> </td>

<td>Public Transport</td>

<td><input name="PublicTransport" type="checkbox" value="" /></td>

<td> </td>

<td>Crime & Comm. Safety</td>

<td><input name="CrimeCommSafety" type="checkbox" value="" /></td>

</tr>

<tr>

<td>Health</td>

<td><input name="Health" type="checkbox" value="" /></td>

<td> </td>

<td>Social Services </td>

<td><input name="Social Services" type="checkbox" value="" /></td>

<td> </td>

<td>Employment & Training</td>

<td><input name="EmploymentTraining" type="checkbox" value="" /></td>

</tr>

</table>

<p> </p>

<p>The information supplied on this form will be stored electronically by BBEMI and Public Sector Organisations in Barnsley.<br>

Your details will only be used for the purposes of the BME Residents Panel and will NOT be passed on to any third party. <br>

<em> <input name="Agree" type="checkbox" value="" />

I agree to my information being used for this purpose. </em></p>

<p> </p>

<p align="center">

</body>

</html>

I know this is not easy work and thats why I am offering you the payment.

Otherwise I would have done myself without asking you for help... I aslo would pay in advanced if you think I am trying to fool you but please do not take the advantes over to fool me instead

BuCki · September 12, 2009

Nobody intrested??

Come on guys, I even want to pay you ...

DEVILofDARKNESS · September 13, 2009

I want to say at least one thing: all those checkboxes are slugish and dangerous for your code, you really need to use radio buttons.

BuCki · September 13, 2009

yeh but you said... Radio Button can be used only one time!?

And I need so many ticks... so can RadioButtons can be used so many times ?!

Anyway... it seems like nobody is intrested for money!

DEVILofDARKNESS · September 13, 2009

What I said is the follwing: Radio Buttons are the same as checkboxes but people have to make a choice which one they choose, with checkboxes they can choose more then one.

So all of the following:

<tr>
    <td width="168">British</td>
    <td width="126"><input type="checkbox" name="British" value="y" /></td>
    <td width="135">African</td>
    <td width="126"><input type="checkbox" name="African" value="y" /></td>
    </tr>
  <tr>
    <td>Irish</td>
    <td><input type="checkbox" name="Irish" value="y" /></td>
    <td>Caribbean</td>
    <td><input type="checkbox" name="Caribbean" value="y" /></td>
    </tr>
  <tr>
    <td>Gypsy & Roma </td>
    <td><input type="checkbox" name="GypsyRoma" value="y" /></td>
    <td>Somalian</td>
    <td><input type="checkbox" name="Somalian" value="y" /></td>
    </tr>
  <tr>
    <td>Eastern Europe </td>
    <td><input type="text" name="EasternEurope" size="18" /></td>
    <td>Other Black </td>
    <td><input type="text" name="OtherBlack" size="18" /></td>
    </tr>
  <tr>

should be done with radio buttons because you only want that people choose one.

BuCki · September 13, 2009

yeh ok thats easy to do...

BUT THE THING WHICH I WANT TO DO ... CANNOT BE DONE

COS I DNT KNOW HOW TO AND NOBODY IS BOTHERED TO HELP ME AND TO GET PAID!

FFS!

BuCki · September 13, 2009

UPDATE:

I AM CURRENTLY IN CONTACT WITH ONE OF THE FORUM MEMBER

WHO IS OFFERED HIS TIME TO HELP ME ON THIS

So ignore the offer of the money cos I got in contact with him 1st

and obviously he is going to get the money once the script is done and working.

THANKS

cbolson · September 13, 2009

Removed my comments as BuCki has now replied to me pm that I sent several hours ago.

Chris

MatthewJ · September 15, 2009

Bucki, I would just like to commend you on your high level of class and patience... FFS!

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