<%@ Language=VBScript %> <%Response.Expires = 0%> <% ct = 0 For each Item in Request.Form ct = ct + 1 rem Response.Write(item & " = " & Request.Form(Item) & "
") Next agencyName = Request.Form("agencyName") emailPreference = Request.Form("emailPreference") DBAName = Request.Form("DBAName") stateCode = Request.Form("stateCode") agencyType = Request.Form("agencyType") agencyNumber = Request.Form("agencyNumber") title = Request.Form("title") address1 = Request.Form("address1") address2 = Request.Form("address2") postalCode = Request.Form("postalCode") firstName = Request.Form("firstName") phoneNr = Request.Form("phoneNr") surName = Request.Form("surName") paymentType = Request.Form("paymentType") email = Request.Form("email") city = Request.Form("city") countryCode = Request.Form("countryCode") bad = false %>
<%=Request.ServerVariables("URL")%>" method=post>
Personal Information
Agency Name * : 
Doing Business As : 
Select ARC or CLIA * :  checked <%End if%> name='agencyType'> ARC/IATA    checked <%End if%> name='agencyType'> CLIA
ARC or CLIA Number * : 
Title : 
First Name * : 
Last Name * : 
Phone w/Area Code * : 
Agent Email * : 
Email preferences * : 
Address 1 * : 
Address 2 : 
Postal Code * : 
City * : 
State * : 
Country * : 
 

Payment
Payment Options * :  checked <%End if%> name='paymentType'> Company Check    checked <%End if%> name='paymentType'> Electronic
 

<%Else%> Please allow 3 to 5 days for processing.
CLIA Agents - Please fax a copy of your certification and business license to "Sales" at 407-831-2470 for validation. <% if ct > 0 then Maitland = "uid=profapp;PWD=trav" set Profits=server.createobject("adodb.connection") myDSN = "DRIVER={MySQL ODBC 3.51 Driver};server=192.168.226.113;database=profits;" & Maitland Profits.open myDSN mySQL = "insert into agntreg" &_ " (AgencyName" &_ ",ARCNumber" &_ ",AgentName" &_ ",AgentEMail" &_ ",Address1" &_ ",Address2" &_ ",City" &_ ",State" &_ ",Postal_Code" &_ ",DBA" &_ ",Address_Country" &_ ",Phone" &_ ") values (" &_ "'" & Replace(agencyName,"'","''") & "'" &_ ",'" & agencyNumber & "'" &_ ",'" & Replace(firstName,"'","''") & " " & Replace(surName,"'","''") & "'" &_ ",'" & email & "'" &_ ",'" & Replace(address1,"'","''") & "'" &_ ",'" & Replace(address2,"'","''") & "'" &_ ",'" & Replace(city,"'","''") & "'" &_ ",'" & Replace(stateCode,"'","''") & "'" &_ ",'" & postalCode & "'" &_ ",'" & Replace(DBAName,"'","''") & "'" &_ ",'" & countryCode & "'" &_ ",'" & Replace(phoneNr,"'","''") & "'" &_ ")" rem Response.Write(mySQL & "
") set rstemp=Profits.execute(mySQL) set rstemp=nothing Profits.close set Profits=nothing End if %> <%End if%> <%if ct = 0 or bad then%> <%End if%>
<%if bad then%>  * Please provide the missing information.

<%if ct <> 0 and Not bad then%> <%End if%>