<!--#include virtual="/include/templates/top.asa"-->

<!--#include virtual="/include/menus/perserverence.asa"-->

<!--#include virtual="/include/constants/database.asa"-->

<!--#include virtual="/members_only/include/common_functions.asa"-->

<%

Dim Applicant_ID

Applicant_ID = GetVal("Applicant_ID", "")



' 2. Create a Recordset Object

Set rsApplicant = Server.CreateObject("ADODB.Recordset")





' 4. If there is a request to update the new record, update the new record

If Request.Form("Submit") = "Submit" Then

	rsApplicant.Open "Application_Perserverence", cnnMain,3,3

	rsApplicant.AddNew

		For Each Item in Request.Form

			if trim(Request.Form(Item)) <> "" and Item <> "Submit" then

				rsApplicant(Item) = Request.Form(Item)

			end if 

		Next

		rsApplicant.Update

	rsApplicant.Close

	

' Send e-mail notification to BCFPD 

		Dim servMess

		Dim servBody



		servBody = "A Perseverence Donation Request Application has been submitted."

        

		Set servMess = Server.CreateObject("JMail.Message")

		

		servMess.AddRecipient "inquiries@dot-1.com"

		servMess.AddRecipient "hq@bcfdmo.com"



		servMess.Logging = true

		servMess.FromName = Request.Form("Namereq")

		servMess.From = Request.Form("Email")

		servMess.Subject = "BCFPD Web Site - Perseverance Request Application"



		servMess.Body = servBody

		servMess.Send("216.251.32.73")



        Set servMess  = Nothing	

End If







%>									

<table cellpadding="5" cellspacing="0" border="0" width="98%">

	<tr>

		<td class="PageTitle">Perseverance Donation Application</td>

	</tr>	

	<tr>

		<td><font size="1"><strong>Items in bold are required.</strong></font></td>

	</tr>

	<tr>

		<td>

			<form method="post" action="index.asp" id="form1" name="form1" onsubmit="return ValidateApp(document.form1.elements, 'You must enter a ');">

			<table border="1" cellpadding="3" cellspacing="0" bordercolor="#f2f2f2">

				<tr>

					<td class="AppLabel" ><b>Name:</b></td>

					<td><input type="text" name="Namereq" size="50" maxlength="100"></td>

				</tr>	

				<tr>

					<td class="AppLabel">Title:</td>

					<td><input type="text" name="Title" size="50" maxlength="100"></td>

				</tr>

				<tr>

					<td class="AppLabel" ><b>Address 1:</b></td>

					<td ><input type="text" name="Address1req" size="50" maxlength="100"></td>

				</tr>

				<tr>

					<td class="AppLabel" >Address 2:</td>

					<td ><input type="text" name="Address2" size="50" maxlength="100"></td>

				</tr>



				<tr>

					<td class="AppLabel" ><b>City:</b></td>

					<td ><input type="text" name="Cityreq" size="50" maxlength="100"></td>

				</tr>

				<tr>

					<td class="AppLabel" ><b>State:</b></td>

					<td ><input type="text" name="Statereq" value="MO" size="2" Maxlength="2"></td>

				</tr>

				<tr>

					<td class="AppLabel" ><b>Zip:</b></td>

					<td ><input type="text" name="Zipreq" size="5" maxlength="5"></td>

				</tr>

				</tr>

				<tr>

					<td class="AppLabel" ><b>Day Time Phone:</b></td>

					<td ><input type="text" name="Day_Time_Phonereq" size="15" maxlength="15"></td>

				</tr>

				<tr>

					<td class="AppLabel" >Night Time Phone:</td>

					<td ><input type="text" name="Night_Time_Phone" size="15" maxlength="15"></td>

				</tr>

				<tr>

					<td class="AppLabel" >Fax:</td>

					<td ><input type="text" name="Fax" size="15" maxlength="15"></td>

				</tr>

				<tr>

					<td class="AppLabel" >E-mail:</td>

					<td ><input type="text" name="Email" size="50" maxlength="100"></td>

				</tr>

			</table>

		</td>

	</tr>

	<tr>

		<td align="center">

			<a href="javascript:submitPlus(document.form1, 'Submit');"><img SRC="/images/buttons/Submit.gif" border="0"></a>

			<input type="Hidden" name="Submit">

		</td>

	</tr>



</table>

			</form>



<%	

	set rsApplicant = Nothing

%>				   		

<!--#include virtual="/include/templates/bottom.asa"-->