<!--#include virtual="/include/templates/sk_top.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_SK", 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 Request for Additional Survival Kids Information has been submitted."

        

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

		

		servMess.AddRecipient "rstephens@bcfdmo.com"

		servMess.Logging = true

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

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

		servMess.Subject = "BCFPD Web Site - Survival Kids Additional Info Request Application"



		servMess.Body = servBody

		servMess.Send("server2.bcfdmo.com")





        Set servMess  = Nothing	

End If







%>

<table cellpadding="5" cellspacing="0" border="0" width="98%" ID="Table1">

	<tr>

		<td class="PageTitle">Survival Kids Information Request 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" ID="Table2">

				<tr>

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

					<td><input type="text" name="Namereq" size="50" maxlength="100" ID="Text1"></td>

				</tr>	

				<tr>

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

					<td><input type="text" name="Title" size="50" maxlength="100" ID="Text2"></td>

				</tr>

				<tr>

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

					<td><input type="text" name="Address1req" size="50" maxlength="100" ID="Text3"></td>

				</tr>

				<tr>

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

					<td><input type="text" name="Address2" size="50" maxlength="100" ID="Text4"></td>

				</tr>



				<tr>

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

					<td><input type="text" name="Cityreq" size="50" maxlength="100" ID="Text5"></td>

				</tr>

				<tr>

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

					<td><input type="text" name="Statereq" value="MO" size="2" Maxlength="2" ID="Text6"></td>

				</tr>

				<tr>

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

					<td><input type="text" name="Zipreq" size="5" maxlength="5" ID="Text7"></td>

				</tr>

				</tr>

				<tr>

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

					<td><input type="text" name="Day_Phonereq" size="15" maxlength="15" ID="Text8"></td>

				</tr>

				<tr>

					<td class="AppLabel">Home Phone:</td>

					<td><input type="text" name="Night_Time_Phone" size="15" maxlength="15" ID="Text9"></td>

				</tr>

				<tr>

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

					<td><input type="text" name="Fax" size="15" maxlength="15" ID="Text10"></td>

				</tr>

				<tr>

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

					<td><input type="text" name="Email" size="50" maxlength="100" ID="Text11"></td>

				</tr>

				<tr>

					<td class="AppLabel"><b>Your Department <br>or School Name:</b></td>

					<td><input type="text" name="DeptNamereq" size="50" maxlength="100" ID="Text12"></td>

				</tr>

				<tr>

					<td class="AppLabel">Fire Chief Name <font size="1">(if applicable)</font></td>

					<td><input type="text" name="FireChief" size="50" maxlength="100" ID="Text13"></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" ID="Hidden1">

		</td>

	</tr>



	<tr>

		<td class="Content">To Contact us for more information....<br>

					573-447-5000<br>

					khines@bcfdmo.com

		</td>

	</tr>

</table>

			</form>



<%	

	set rsApplicant = Nothing

%>				   		

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