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Create Form - Send Confirmation To 2 Different Emails

justspiffy

By justspiffy
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justspiffy Member

justspiffy

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Posted

Hi there,

I am new to PHP and I am having an issue creating a form that sends conformation to two different people. One needs to be sent to the person who fills the form out and one needs to be sent to the company who made the form.

 

What also needs to happen, is there is a field that asks the customer to enter their credit card. When the person who fills the form out receive the confirmation email, I need the credit card info to be X X X'd out. And when the company receives the email the credit card needs to be visible.

 

I have tried and what I have come up with sends 2 emails to both customer and company. They both receive 2 emails, one with it X X X'd out and another with the credit card, but that is not what I want. I need only 1 email each, customer with the credit card X X X'd out and company with it visible. Can anyone help me?

 

Here is my code:

 

<!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>Cat & Dog Tag Renewal Form</title>
<script language="javascript" type="text/javascript">
//<![CDATA[
var tl_loc0=(window.location.protocol == "https:")? "https://secure.comodo.net/trustlogo/javascript/trustlogo.js" :
"http://www.trustlogo.com/trustlogo/javascript/trustlogo.js";
document.writeln('<scr' + 'ipt language="JavaScript" src="'+tl_loc0+'" type="text\/javascript">' + '<\/scr' + 'ipt>');
//]]>
</script>

</head>

<body topmargin ="0" leftmargin="0" marginwidth="0" marginheight="0" onLoad="createExpiry();">

<p><img border="0" src="images/header.jpg" width="675" height="119"></p>

<table border="0" width="800" cellspacing="0" cellpadding="0">
  <tr>
    <td width="3%"></td>
    <td width="97%">

<?php
if ($_SERVER['REQUEST_METHOD'] != 'POST'){
      $me = $_SERVER['PHP_SELF'];

?>


<form name="form1" method="post"
         action="<?php echo $me;?>">
<table border="0" width="483" height="48" cellspacing="0" cellpadding="0">
    <tr>
      <td width="114" height="19" valign="middle">Please Enter ID #:</td>
      <td width="160" height="19" align="center" valign="middle">
       
  <input type="text" name="ID_Number" size="22" tabindex="1" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
      <td width="203" height="19" align="center">
  (found above surname on your invoice)</td>
    </tr>
    <tr>
      <td width="114" height="19"></td>
      <td width="160" height="19" align="center"></td>
      <td width="203" height="19" align="center"></td>
    </tr>
    <tr>
      <td width="114" height="19" valign="bottom">Name:</td>
      <td width="160" height="19" align="center">
       
  <input type="text" name="Surname" size="22" tabindex="2" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
      <td width="203" height="19" align="center" valign="bottom">
       
  <input type="text" name="Given_Name" size="25" tabindex="3" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="114" height="17"></td>
      <td width="160" height="17" align="center">(Surname)</td>
      <td width="203" height="17" align="center">(Given)</td>
    </tr>
    <tr>
      <td width="114" height="17">E-Mail Address:</td>
      <td width="363" height="17" align="center" colspan="2">
        <p align="left"> 
	<input type="text" name="Email_Address" size="42" tabindex="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
     <tr height=5>
         <td align="center" colspan="3">
         </td>
     </tr>
     <tr>
         <td align=center colspan=3>
            <font size=2>*a confirmation number will be emailed to the above addess upon submission</font>
         </td>
     </tr>
     <tr height=15>
         <td align="center" colspan="3">
         </td>
     </tr>
</table>
  <table width="485" height="50" cellspacing="0" cellpadding="2" style="border-width:1px;border-color:#ff0000;border-style:solid">
    <tr>
       <td colspan="2" width="485" height="19">Have you had a change in address or phone number over the last year?</td>
    </tr>
    <tr>
       <td><input type="radio" value="change_yes" name="Contact_Change" tabindex="5">Yes</td>
    </tr>
    <tr>
       <td><input type="radio" value="change_no" name="Contact_Change" tabindex="6">No</td>
    </tr>
  </table>
<br/>
<table border="0" width="485" height="100" cellspacing="0" cellpadding="0">
    <tr>
      <td width="305" height="19">Address:</td>
      <td width="390" height="19" align="left">
       
  <input type="text" name="Address" size="51" tabindex="7" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="305" height="17"></td>
      <td width="390" height="17" align="left">Apt#      
        Street#         Street</td>
    </tr>
    <tr>
      <td width="305" height="15"></td>
      <td width="390" height="15" align="center"></td>
    </tr>
    <tr>
      <td width="305" height="17">Municipality:</td>
      <td width="390" height="17" align="left">
       
  <input type="text" name="Municipality" size="22" value="London" tabindex="8" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="305" height="17">Province:</td>
      <td width="390" height="17" align="left">
       
  <input type="text" name="Province" size="22" tabindex="9" value="ON" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="305" height="17">Postal Code:</td>
      <td width="390" height="17" align="left">
       
  <input type="text" name="Postal_Code" size="22" tabindex="10" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="305" height="17"></td>
      <td width="390" height="17" align="left"></td>
    </tr>
    <tr>
      <td width="305" height="17" rowspan="2">Phone #<br/>(with area code):</td>
      <td width="390" height="17" align="left">Home:
  <input type="text" name="Phone_Home" size="12" tabindex="11" maxlength="12" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"> (eg. 519-555-5555)</td>
    </tr>
    <tr>
      <td width="390" height="17" align="left">Work:      
  <input type="text" name="Phone_Work" size="12" tabindex="12" maxlength="12" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"> 
        ext: <input type="text" name="Phone_Work_Extension" size="8" tabindex="13" maxlength="8" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
  </table>
  <p> 



  </p>
  <table border="0" width="538" cellspacing="0" cellpadding="0">
    <tr>
      <td width="130"><b>Billing Information</b></td>
      <td width="234"></td>
    </tr>
    <tr>
      <td width="130" rowspan="2">
	<!-- Authentic Trust Logo Seal verification code START -->
	<!--
TrustLogo Html Builder Code:
Shows the logo at URL http://www.accpets.ca/images/trust_logo.GIF
Logo type is  ("SC4")
Not Floating
//-->
<a href="http://www.instantssl.com" id="comodoTL">SSL</a>
<script type="text/javascript">TrustLogo("http://www.accpets.ca/images/trust_logo.GIF", "SC4", "none");</script>
	<!-- Authentic Trust Logo Seal verification code END -->
     </td>
      <td width="234"><input type="radio" value="MasterCard" name="Card_Type" tabindex="14" checked>MasterCard</td>
    </tr>
    <tr>
      <td width="234"><input type="radio" value="Visa" name="Card_Type" tabindex="15">Visa</td>
    </tr>
    <tr>
      <td width="130"></td>
      <td width="234"></td>
    </tr>
    <tr>
            <td width="130">Name of Cardholder:</td>
      <td width="234"><input type="text" name="CreditCardName" size="45" tabindex="16" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="130">Card #: </td>
      <td width="300">
       
  <input type="text" name="CardNumber" size="4" tabindex="17" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">  
  <input type="text" name="CardNumber1" size="4" tabindex="18" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">  
  <input type="text" name="CardNumber2" size="4" tabindex="19" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">  
  <input type="text" name="CardNumber3" size="4" tabindex="20" maxlength="4" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="130">Expiry Date: </td>
      <td width="234">
       
  <select size="1" name="Expiry_Month" tabindex="21" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>MM</option>
          <option>01</option>
          <option>02</option>
          <option>03</option>
          <option>04</option>
          <option>05</option>
          <option>06</option>
          <option>07</option>
          <option>08</option>
          <option>09</option>
          <option>10</option>
          <option>11</option>
          <option>12</option>
        </select> 
  <select size="1" name="Expiry_Year" tabindex="22" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>YYYY</option>
	  	  <option>2009</option>
          <option>2010</option>
          <option>2011</option>
          <option>2012</option>
          <option>2013</option>
          <option>2014</option>
          <option>2015</option>
          <option>2016</option>
          <option>2017</option>
          <option>2018</option>
        </select></td>
    </tr>
  </table>
  <p>Please indicate amount to be paid: $   <input type="text" name="Amount_Paid" size="13" tabindex="23" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></p>
  <p> </p>
  <table border="0" width="539" cellspacing="0" cellpadding="0" height="69">
    <tr>
      <td width="262" height="21"><b>Rabies Information</b></td>
      <td width="261" height="21"></td>
    </tr>
    <tr>
      <td width="262" height="25">Veterinarian Clinic Name</td>
      <td width="261" height="25" valign="middle">
       
  <input type="text" name="vet_clinic_name" size="20" tabindex="24" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
              <br>
              <br>
            </td>
    </tr>
    <tr>
      <td width="262" height="23">Name of First Animal</td>
      <td width="261" height="23">
       
  <input type="text" name="Animal1_Name" size="20" tabindex="25" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="262" height="23">Month and Year of Vaccination</td>
      <td width="261" height="23">
       
  <select size="1" name="Rabies_Month_Animal1" tabindex="26" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>MM</option>
          <option value="January">January</option>
          <option value="February">February</option>
          <option value="March">March</option>
          <option value="April">April</option>
          <option value="May">May</option>
          <option value="June">June</option>
          <option value="July">July</option>
          <option value="August">August</option>
          <option value="September">September</option>
          <option value="October">October</option>
          <option value="November">November</option>
          <option value="December">December</option>
        </select>  
  <select size="1" name="Rabies_Year_Animal1" tabindex="27" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>YYYY</option>    
	    <option>2002</option>
          <option>2003</option>
          <option>2004</option>
          <option>2005</option>
          <option>2006</option>
          <option>2007</option>
          <option>2008</option>
          <option>2009</option>
          <option>2010</option>
          <option>2011</option>       
        </select>
              <br>
              <br>
            </td>
    </tr>
    <tr>
      <td width="262" height="23">Name of Second Animal</td>
      <td width="261" height="23">
      <input type="text" name="Animal2_Name" size="20" tabindex="28" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="262" height="23">Month and Year of Vaccination</td>
      <td width="261" height="23">
      <select size="1" name="Rabies_Month_Animal2" tabindex="29" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>MM</option>
          <option value="January">January</option>
          <option value="February">February</option>
          <option value="March">March</option>
          <option value="April">April</option>
          <option value="May">May</option>
          <option value="June">June</option>
          <option value="July">July</option>
          <option value="August">August</option>
          <option value="September">September</option>
          <option value="October">October</option>
          <option value="November">November</option>
          <option value="December">December</option>
        </select>
	<select size="1" name="Rabies_Year_Animal2" tabindex="30" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>YYYY</option>
	    <option>2002</option>
          <option>2003</option>
          <option>2004</option>
          <option>2005</option>
          <option>2006</option>
          <option>2007</option>
          <option>2008</option>
          <option>2009</option>
          <option>2010</option>
          <option>2011</option>      
        </select>
              <br>
              <br>
            </td>
    </tr>
    <tr>
      <td width="262" height="23">Name of Third Animal</td>
      <td width="261" height="23">
      <input type="text" name="Animal3_Name" size="20" tabindex="31" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></td>
    </tr>
    <tr>
      <td width="262" height="23">Month and Year of Vaccination</td>
      <td width="261" height="23">
      <select size="1" name="Rabies_Month_Animal3" tabindex="32" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>MM</option>
          <option value="January">January</option>
          <option value="February">February</option>
          <option value="March">March</option>
          <option value="April">April</option>
          <option value="May">May</option>
          <option value="June">June</option>
          <option value="July">July</option>
          <option value="August">August</option>
          <option value="September">September</option>
          <option value="October">October</option>
          <option value="November">November</option>
          <option value="December">December</option>
        </select>
	<select size="1" name="Rabies_Year_Animal3" tabindex="33" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'">
          <option>YYYY</option>
	    <option>2002</option>
          <option>2003</option>
          <option>2004</option>
          <option>2005</option>
          <option>2006</option>
          <option>2007</option>
          <option>2008</option>
          <option>2009</option>
          <option>2010</option>
          <option>2011</option> 
        </select></td>
    </tr>
  </table>
  <table>
    <tr height="15">
        <td></td>
    </tr>
  </table>
  <table border="0" cellpadding="0" cellspacing="0" width="600">
    <tr>
        <td><strong>Breed Certification</strong><br /><i>(if only renewing cat identification tags, please select the
            Cat renewal only box)</i>
        </td>
    </tr>
    <tr height="10">
        <td>
        </td>
    </tr>
    <tr>
        <td><input type="radio" name="DogOrCat" value="No Pit Bull - Declared" />I am the Owner of the
            above indicated dog(s) and the dog(s) is/are not Pit Bull dog(s)<br />     as defined in the
            City of London's Pit Bull dog licensing by-law.
        </td>
    </tr>
    <tr>
        <td><input type="radio" name="DogOrCat" value="Cat renewal only" />Cat renewal only</td>
    </tr>
  </table>
  <p> </p>
  <p>Notes: If amount to be paid does not match amount invoiced, please explain
  in the box provided.<b>*</b></p>
  <p>    <textarea rows="4" name="Notes" cols="72" tabindex="34" OnFocus="this.style.backgroundColor='#D0E0F0'" OnBlur="this.style.backgroundColor='#FFFFFF'"></textarea></p>
  <p><b>*If spay/neuter has occurred in past year, please provide veterinary
  name and phone number for follow up.</b></p>
        <p align="center"> 
          <input type="submit" value="Submit" name="B1">
          <input type="reset" value="Reset" name="B2">
        </p>
        </form>
</table>


<?php
   } else {
      error_reporting(0);
      $recipient = 'contact@justspiffy.ca';
  $ID_Number = stripslashes($_POST['ID_Number']);
      $Surname = stripslashes($_POST['Surname']);
  $Given_name = stripslashes($_POST['Given_name']);
  $Email_Address = stripslashes($_POST['Email_Address']);
      $Contact_Change = stripslashes($_POST['Contact_Change']);
      $Address = stripslashes($_POST['Address']);
  $Municipality = stripslashes($_POST['Municipality']);
      $Province = stripslashes($_POST['Province']);
  $Postal_Code = stripslashes($_POST['Postal_Code']);
      $Phone_Home = stripslashes($_POST['Phone_Home']);
      $Phone_Work = stripslashes($_POST['Phone_Work']);
      $Phone_Work_Extension = stripslashes($_POST['Phone_Work_Extension']);
  $Card_Type = stripslashes($_POST['Card_Type']);
  $CreditCardName = stripslashes($_POST['CreditCardName']);
      $CardNumber = stripslashes($_POST['CardNumber']);
      $CardNumber1 = stripslashes($_POST['CardNumber1']);
      $CardNumber2 = stripslashes($_POST['CardNumber2']);
      $CardNumber3 = stripslashes($_POST['CardNumber3']);
  $Expiry_Month = stripslashes($_POST['Expiry_Month']);
      $Expiry_Year = stripslashes($_POST['Expiry_Year']);
      $Amount_Paid = stripslashes($_POST['Amount_Paid']);
  $vet_clinic_name = stripslashes($_POST['vet_clinic_name']);
  $Animal1_Name = stripslashes($_POST['Animal1_Name']);
      $Rabies_Month_Animal1 = stripslashes($_POST['Rabies_Month_Animal1']);
      $Rabies_Year_Animal1 = stripslashes($_POST['Rabies_Year_Animal1']);
      $Animal2_Name = stripslashes($_POST['Animal2_Name']);
      $Rabies_Month_Animal2 = stripslashes($_POST['Rabies_Month_Animal2']);
  $Rabies_Year_Animal2 = stripslashes($_POST['Rabies_Year_Animal2']);
  $Animal3_Name = stripslashes($_POST['Animal3_Name']);
  $Rabies_Month_Animal3 = stripslashes($_POST['Rabies_Month_Animal3']);
  $Rabies_Year_Animal3 = stripslashes($_POST['Rabies_Year_Animal3']);
  $DogOrCat = stripslashes($_POST['DogOrCat']);
  $Notes = stripslashes($_POST['Notes']);
      
      $sendto = $_POST['Email_Address'];
      $headers = "From: $recipient\r\n\r\n";
      $subject = "Dog & Cat Tag Renewal";
      $message = "Thank you for registering your pet with London Animal Care Centre.\n
			  Please keep this email as proof of your application for your 
			  dog licence or cat identification tag.<br />

			  Your confirmation Id is \n
			    
			  If you have any questions or concerns please call (519)685-1330
			  and have your confirmation id available.\n
			  Please allow 3 to 6 weeks for processing and delivery of your tags.\n
  
      ID #: $ID_Number\r\n
      Name: $Surname  $Given_name\r\n
      E-Mail Address: $Email_Address\r\n
      Have you had a change in address or phone number over the last year?: $Contact_Change\r\n
      Address: $Address\r\n
      Municipality: $Municipality\r\n
      Province: $Province\r\n
  Postal Code: $Postal_Code\r\n
      Phone # - Home: $Phone_Home\r\n
      Phone # - Work: $Phone_Work\r\n
      Work Ext: $Phone_Work_Extension\r\n
      Card Type: $Card_Type\r\n
      Name of Cardholder: $CreditCardName\r\n
      Card #: XXXX-XXXX-XXXX-$CardNumber3\r\n
      Expiry Date: $Expiry_Month  $Expiry_Year\r\n
      Please indicate amount to be paid: $Amount_Paid\r\n
      Veterinarian Clinic Name: $vet_clinic_name\r\n
      Name of First Animal: $Animal1_Name\r\n
      Month and Year of Vaccination: $Rabies_Month_Animal1  $Rabies_Year_Animal1\r\n
  Name of Second Animal: $Animal2_Name\r\n
      Month and Year of Vaccination: $Rabies_Month_Animal2  $Rabies_Year_Animal2\r\n
      Name of Third Animal: $Animal3_Name\r\n
      Month and Year of Vaccination: $Rabies_Month_Animal3  $Rabies_Year_Animal3\r\n
      Breed Certification: $DogOrCat\r\n
      Notes: $Notes\r\n
      ";
      // Send mail to customer, refer to http://php.net/manual/en/function.mail.php
      mail($recipient, $subject, $message, $headers, $sendto);
      if (!mail) {
          echo "Message failed to send, please notify our Web Team.";
      } else {
          echo nl2br ("<center><br><br><br><br><br><br><br><br><br><br>Thank you. Your request has been sent and we will contact you shortly.<br><br><br><br><br><br><br><br><br><br></center>");
      }
      // Send mail to company
      $to = "contact@justspiffy.ca"; // who gets this one?
      $from = $sendto; // Set From to the person who filled out the form
      $card = "$CardNumber $CardNumber1  $CardNumber2  $CardNumber3\r\n"; // build the credit card number
      $message = "$message1 $card"; // tack the CC number to end of the message you already built above
      mail($to, $subject, $message, $headers, $from);
       if (!mail) {
          echo "Message failed to send. Please notify our Web Team.";
      } else {
          // something here to notify the web team if it fails.
      }
}
?>



<p>    
<!-- Seal verification code START -->  <!-- Seal verification code END --></p>
</body>
</html>

 

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iPixel Advanced Member

iPixel

Posted
Posted

What you do is create an email array, the default company email and the user entered email(their own)

Then foreach email you run your email script that emails the person... but for the XXXXX's you simply do...

 

if($email == "usersemail") change C.C. numbers to XXXXXX's

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