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  1. <!-- BHMS Submission Form -->
  2.  
  3.  
  4.  
  5. <html>
  6.  
  7. <head>
  8. <script src="https://code.jquery.com/jquery-3.1.1.min.js"></script>
  9.  
  10. </head>
  11.  
  12. <body>
  13.  
  14. <font face="Arial">
  15.  
  16. <form id="myForm" name="myForm" >
  17.  
  18. <br>
  19.  
  20. BHMS Zopim Chat Entry
  21.  
  22. <br>
  23.  
  24. <br>
  25.  
  26. <table border="0">
  27.  
  28. <tr>
  29.  
  30. <td>Agent:</td> <td><select name="agentname">
  31.  
  32. <option value="Lucy">Lucy</option>
  33.  
  34. <option value="Monique">Monique</option>
  35.  
  36. <option value="Lara">Lara</option>
  37.  
  38. <option value="Gast">Gast</option>
  39.  
  40. </select></td>
  41.  
  42. </tr>
  43.  
  44. <tr>
  45.  
  46. <td>First Name:</td><td><input type="text" name="firstName"></td>
  47.  
  48. </tr>
  49.  
  50. <tr>
  51.  
  52. <td>Last Name:</td> <td><input type="text" name="lastName"></td>
  53.  
  54. </tr>
  55.  
  56. <tr>
  57.  
  58. <td>getKnow:</td> <td><input type="text" name="getKnow"></td>
  59.  
  60. </tr>
  61.  
  62. <tr>
  63.  
  64. <td>Mobile Phone #:</td> <td><input type="number" name="mobilePhone"></td>
  65.  
  66. </tr>
  67.  
  68. <tr>
  69.  
  70. <td>E-mail Address:</td> <td><input type="email" name="emailAddress"></td>
  71.  
  72. </tr>
  73.  
  74.  
  75.  
  76.  
  77.  
  78. <tr>
  79.  
  80. <td>Country:</td> <td><select name="country">
  81.  
  82. <option value="Afghanistan">Afghanistan</option>
  83.  
  84. <option value="Aland_Islands">Aland_Islands</option>
  85.  
  86. <option value="Albania">Albania</option>
  87.  
  88. <option value="Algeria">Algeria</option>
  89.  
  90. <option value="American_Samoa">American_Samoa</option>
  91.  
  92. <option value="Andorra">Andorra</option>
  93.  
  94. <option value="Angola">Angola</option>
  95.  
  96. <option value="Anguilla">Anguilla</option>
  97.  
  98. <option value="Antarctica">Antarctica</option>
  99.  
  100. <option value="Antigua_and_Barbuda">Antigua_and_Barbuda</option>
  101.  
  102. <option value="Argentina">Argentina</option>
  103.  
  104. <option value="Armenia">Armenia</option>
  105.  
  106. <option value="Aruba">Aruba</option>
  107.  
  108. <option value="Australia">Australia</option>
  109.  
  110. <option value="Austria">Austria</option>
  111.  
  112. <option value="Azerbaijan">Azerbaijan</option>
  113.  
  114. <option value="Bahamas">Bahamas</option>
  115.  
  116. <option value="Bahrain">Bahrain</option>
  117.  
  118. <option value="Bangladesh">Bangladesh</option>
  119.  
  120. <option value="Barbados">Barbados</option>
  121.  
  122. <option value="Belarus">Belarus</option>
  123.  
  124. <option value="Belgium">Belgium</option>
  125.  
  126. <option value="Belize">Belize</option>
  127.  
  128. <option value="Benin">Benin</option>
  129.  
  130. <option value="Bermuda">Bermuda</option>
  131.  
  132. <option value="Bhutan">Bhutan</option>
  133.  
  134. <option value="Bolivia">Bolivia</option>
  135.  
  136. <option value="Bonaire,_Sint_Eustatius_and_Saba">Bonaire,_Sint_Eustatius_and_Saba</option>
  137.  
  138. <option value="Bosnia_and_Herzegovina">Bosnia_and_Herzegovina</option>
  139.  
  140. <option value="Botswana">Botswana</option>
  141.  
  142. <option value="Bouvet_Island">Bouvet_Island</option>
  143.  
  144. <option value="Brazil">Brazil</option>
  145.  
  146. <option value="British_Indian_Ocean_Territory">British_Indian_Ocean_Territory</option>
  147.  
  148. <option value="Brunei_Darussalam">Brunei_Darussalam</option>
  149.  
  150. <option value="Bulgaria">Bulgaria</option>
  151.  
  152. <option value="Burkina_Faso">Burkina_Faso</option>
  153.  
  154. <option value="Burundi">Burundi</option>
  155.  
  156. <option value="Cambodia">Cambodia</option>
  157.  
  158. <option value="Cameroon">Cameroon</option>
  159.  
  160. <option value="Canada">Canada</option>
  161.  
  162. <option value="Cape_Verde">Cape_Verde</option>
  163.  
  164. <option value="Cayman_Islands">Cayman_Islands</option>
  165.  
  166. <option value="Central_African_Republic">Central_African_Republic</option>
  167.  
  168. <option value="Chad">Chad</option>
  169.  
  170. <option value="Chile">Chile</option>
  171.  
  172. <option value="China">China</option>
  173.  
  174. <option value="Christmas_Island">Christmas_Island</option>
  175.  
  176. <option value="Cocos_(Keeling)_Islands">Cocos_(Keeling)_Islands</option>
  177.  
  178. <option value="Colombia">Colombia</option>
  179.  
  180. <option value="Comoros">Comoros</option>
  181.  
  182. <option value="Congo">Congo</option>
  183.  
  184. <option value="Congo,_Democratic_Republic_of">Congo,_Democratic_Republic_of</option>
  185.  
  186. <option value="Cook_Islands">Cook_Islands</option>
  187.  
  188. <option value="Costa_Rica">Costa_Rica</option>
  189.  
  190. <option value="Cote_D_ivoire">Cote_D_ivoire</option>
  191.  
  192. <option value="Croatia">Croatia</option>
  193.  
  194. <option value="Cuba">Cuba</option>
  195.  
  196. <option value="Curacao">Curacao</option>
  197.  
  198. <option value="Cyprus">Cyprus</option>
  199.  
  200. <option value="Czech_Republic">Czech_Republic</option>
  201.  
  202. <option value="Denmark">Denmark</option>
  203.  
  204. <option value="Djibouti">Djibouti</option>
  205.  
  206. <option value="Dominica">Dominica</option>
  207.  
  208. <option value="Dominican_Republic">Dominican_Republic</option>
  209.  
  210. <option value="East_Timor">East_Timor</option>
  211.  
  212. <option value="Ecuador">Ecuador</option>
  213.  
  214. <option value="Egypt">Egypt</option>
  215.  
  216. <option value="El_Salvador">El_Salvador</option>
  217.  
  218. <option value="Equatorial_Guinea">Equatorial_Guinea</option>
  219.  
  220. <option value="Eritrea">Eritrea</option>
  221.  
  222. <option value="Estonia">Estonia</option>
  223.  
  224. <option value="Ethiopia">Ethiopia</option>
  225.  
  226. <option value="Falkland_Islands">Falkland_Islands</option>
  227.  
  228. <option value="Faroe_Islands">Faroe_Islands</option>
  229.  
  230. <option value="Fiji">Fiji</option>
  231.  
  232. <option value="Finland">Finland</option>
  233.  
  234. <option value="France">France</option>
  235.  
  236. <option value="French_Guiana">French_Guiana</option>
  237.  
  238. <option value="French_Polynesia">French_Polynesia</option>
  239.  
  240. <option value="French_Southern_Territories">French_Southern_Territories</option>
  241.  
  242. <option value="Gabon">Gabon</option>
  243.  
  244. <option value="Gambia">Gambia</option>
  245.  
  246. <option value="Georgia">Georgia</option>
  247.  
  248. <option value="Germany">Germany</option>
  249.  
  250. <option value="Ghana">Ghana</option>
  251.  
  252. <option value="Gibraltar">Gibraltar</option>
  253.  
  254. <option value="Greece">Greece</option>
  255.  
  256. <option value="Greenland">Greenland</option>
  257.  
  258. <option value="Grenada">Grenada</option>
  259.  
  260. <option value="Guadeloupe">Guadeloupe</option>
  261.  
  262. <option value="Guam">Guam</option>
  263.  
  264. <option value="Guatemala">Guatemala</option>
  265.  
  266. <option value="Guernsey">Guernsey</option>
  267.  
  268. <option value="Guinea">Guinea</option>
  269.  
  270. <option value="Guinea-Bissau">Guinea-Bissau</option>
  271.  
  272. <option value="Guyana">Guyana</option>
  273.  
  274. <option value="Haiti">Haiti</option>
  275.  
  276. <option value="Heard_IslandandMcDonald_Islands">Heard_IslandandMcDonald_Islands</option>
  277.  
  278. <option value="Honduras">Honduras</option>
  279.  
  280. <option value="Hong_Kong">Hong_Kong</option>
  281.  
  282. <option value="Hungary">Hungary</option>
  283.  
  284. <option value="Iceland">Iceland</option>
  285.  
  286. <option value="India">India</option>
  287.  
  288. <option value="Indonesia">Indonesia</option>
  289.  
  290. <option value="Iran">Iran</option>
  291.  
  292. <option value="Iraq">Iraq</option>
  293.  
  294. <option value="Ireland">Ireland</option>
  295.  
  296. <option value="Isle_of_Man">Isle_of_Man</option>
  297.  
  298. <option value="Israel">Israel</option>
  299.  
  300. <option value="Italy">Italy</option>
  301.  
  302. <option value="Jamaica">Jamaica</option>
  303.  
  304. <option value="Japan">Japan</option>
  305.  
  306. <option value="Jersey">Jersey</option>
  307.  
  308. <option value="Jordan">Jordan</option>
  309.  
  310. <option value="Kazakhstan">Kazakhstan</option>
  311.  
  312. <option value="Kenya">Kenya</option>
  313.  
  314. <option value="Kiribati">Kiribati</option>
  315.  
  316. <option value="Korea,_Peoples_Republic_of">Korea,_Peoples_Republic_of</option>
  317.  
  318. <option value="Korea,_Republic_of">Korea,_Republic_of</option>
  319.  
  320. <option value="Kosovo">Kosovo</option>
  321.  
  322. <option value="Kuwait">Kuwait</option>
  323.  
  324. <option value="Kyrgyzstan">Kyrgyzstan</option>
  325.  
  326. <option value="Laos">Laos</option>
  327.  
  328. <option value="Latvia">Latvia</option>
  329.  
  330. <option value="Lebanon">Lebanon</option>
  331.  
  332. <option value="Lesotho">Lesotho</option>
  333.  
  334. <option value="Liberia">Liberia</option>
  335.  
  336. <option value="Libya">Libya</option>
  337.  
  338. <option value="Liechtenstein">Liechtenstein</option>
  339.  
  340. <option value="Lithuania">Lithuania</option>
  341.  
  342. <option value="Luxembourg">Luxembourg</option>
  343.  
  344. <option value="Macao">Macao</option>
  345.  
  346. <option value="Macedonia">Macedonia</option>
  347.  
  348. <option value="Madagascar">Madagascar</option>
  349.  
  350. <option value="Malawi">Malawi</option>
  351.  
  352. <option value="Malaysia">Malaysia</option>
  353.  
  354. <option value="Maldives">Maldives</option>
  355.  
  356. <option value="Mali">Mali</option>
  357.  
  358. <option value="Malta">Malta</option>
  359.  
  360. <option value="Marshall_Islands">Marshall_Islands</option>
  361.  
  362. <option value="Martinique">Martinique</option>
  363.  
  364. <option value="Mauritania">Mauritania</option>
  365.  
  366. <option value="Mauritius">Mauritius</option>
  367.  
  368. <option value="Mayotte">Mayotte</option>
  369.  
  370. <option value="Mexico">Mexico</option>
  371.  
  372. <option value="Micronesia">Micronesia</option>
  373.  
  374. <option value="Moldova,_Republic_of">Moldova,_Republic_of</option>
  375.  
  376. <option value="Monaco">Monaco</option>
  377.  
  378. <option value="Mongolia">Mongolia</option>
  379.  
  380. <option value="Montenegro">Montenegro</option>
  381.  
  382. <option value="Montserrat">Montserrat</option>
  383.  
  384. <option value="Morocco">Morocco</option>
  385.  
  386. <option value="Mozambique">Mozambique</option>
  387.  
  388. <option value="Myanmar">Myanmar</option>
  389.  
  390. <option value="Namibia">Namibia</option>
  391.  
  392. <option value="Nauru">Nauru</option>
  393.  
  394. <option value="Nepal">Nepal</option>
  395.  
  396. <option value="Netherlands">Netherlands</option>
  397.  
  398. <option value="Netherlands_Antilles">Netherlands_Antilles</option>
  399.  
  400. <option value="New_Caledonia">New_Caledonia</option>
  401.  
  402. <option value="New_Zealand">New_Zealand</option>
  403.  
  404. <option value="Nicaragua">Nicaragua</option>
  405.  
  406. <option value="Niger">Niger</option>
  407.  
  408. <option value="Nigeria">Nigeria</option>
  409.  
  410. <option value="Niue">Niue</option>
  411.  
  412. <option value="Norfolk_Island">Norfolk_Island</option>
  413.  
  414. <option value="Northern_Mariana_Islands">Northern_Mariana_Islands</option>
  415.  
  416. <option value="Norway">Norway</option>
  417.  
  418. <option value="Oman">Oman</option>
  419.  
  420. <option value="Pakistan">Pakistan</option>
  421.  
  422. <option value="Palau">Palau</option>
  423.  
  424. <option value="Palestinia">Palestinia</option>
  425.  
  426. <option value="Panama">Panama</option>
  427.  
  428. <option value="Papua_New_Guinea">Papua_New_Guinea</option>
  429.  
  430. <option value="Paraguay">Paraguay</option>
  431.  
  432. <option value="Peru">Peru</option>
  433.  
  434. <option value="Philippines">Philippines</option>
  435.  
  436. <option value="Pitcairn">Pitcairn</option>
  437.  
  438. <option value="Poland">Poland</option>
  439.  
  440. <option value="Portugal">Portugal</option>
  441.  
  442. <option value="Puerto_Rico">Puerto_Rico</option>
  443.  
  444. <option value="Qatar">Qatar</option>
  445.  
  446. <option value="Reunion">Reunion</option>
  447.  
  448. <option value="Romania">Romania</option>
  449.  
  450. <option value="Russian_Federation">Russian_Federation</option>
  451.  
  452. <option value="Rwanda">Rwanda</option>
  453.  
  454. <option value="Saint_Barthelemy">Saint_Barthelemy</option>
  455.  
  456. <option value="Saint_Helena">Saint_Helena</option>
  457.  
  458. <option value="Saint_Kitts_and_Nevis">Saint_Kitts_and_Nevis</option>
  459.  
  460. <option value="Saint_Lucia">Saint_Lucia</option>
  461.  
  462. <option value="Saint_Martin_(French_part)">Saint_Martin_(French_part)</option>
  463.  
  464. <option value="Saint_Pierre_and_Miquelon">Saint_Pierre_and_Miquelon</option>
  465.  
  466. <option value="Saint_Vincent_and_the_Grenadines">Saint_Vincent_and_the_Grenadines</option>
  467.  
  468. <option value="Samoa">Samoa</option>
  469.  
  470. <option value="San_Marino">San_Marino</option>
  471.  
  472. <option value="Sao_Tome_and_Principe">Sao_Tome_and_Principe</option>
  473.  
  474. <option value="Saudi_Arabia">Saudi_Arabia</option>
  475.  
  476. <option value="Senegal">Senegal</option>
  477.  
  478. <option value="Serbia">Serbia</option>
  479.  
  480. <option value="Seychelles">Seychelles</option>
  481.  
  482. <option value="Sierra_Leone">Sierra_Leone</option>
  483.  
  484. <option value="Singapore">Singapore</option>
  485.  
  486. <option value="Sint_Maarten_(Dutch_part)">Sint_Maarten_(Dutch_part)</option>
  487.  
  488. <option value="Slovakia">Slovakia</option>
  489.  
  490. <option value="Slovenia">Slovenia</option>
  491.  
  492. <option value="Solomon_Islands">Solomon_Islands</option>
  493.  
  494. <option value="Somalia">Somalia</option>
  495.  
  496. <option value="South_Africa">South_Africa</option>
  497.  
  498. <option value="South_Georgia">South_Georgia</option>
  499.  
  500. <option value="South_Sudan">South_Sudan</option>
  501.  
  502. <option value="Spain">Spain</option>
  503.  
  504. <option value="Sri_Lanka">Sri_Lanka</option>
  505.  
  506. <option value="Sudan">Sudan</option>
  507.  
  508. <option value="Suriname">Suriname</option>
  509.  
  510. <option value="Svalbard_and_Jan_Mayen">Svalbard_and_Jan_Mayen</option>
  511.  
  512. <option value="Swaziland">Swaziland</option>
  513.  
  514. <option value="Sweden">Sweden</option>
  515.  
  516. <option value="Switzerland">Switzerland</option>
  517.  
  518. <option value="Syrian_Arab_Republic">Syrian_Arab_Republic</option>
  519.  
  520. <option value="Taiwan">Taiwan</option>
  521.  
  522. <option value="Tajikistan">Tajikistan</option>
  523.  
  524. <option value="Tanzania">Tanzania</option>
  525.  
  526. <option value="Thailand">Thailand</option>
  527.  
  528. <option value="Togo">Togo</option>
  529.  
  530. <option value="Tokelau">Tokelau</option>
  531.  
  532. <option value="Tonga">Tonga</option>
  533.  
  534. <option value="Trinidad_and_Tobago">Trinidad_and_Tobago</option>
  535.  
  536. <option value="Tunisia">Tunisia</option>
  537.  
  538. <option value="Turkey">Turkey</option>
  539.  
  540. <option value="Turkmenistan">Turkmenistan</option>
  541.  
  542. <option value="Turks_and_Caicos_Islands">Turks_and_Caicos_Islands</option>
  543.  
  544. <option value="Tuvalu">Tuvalu</option>
  545.  
  546. <option value="Uganda">Uganda</option>
  547.  
  548. <option value="Ukraine">Ukraine</option>
  549.  
  550. <option value="United_Arab_Emirates">United_Arab_Emirates</option>
  551.  
  552. <option value="United_Kingdom">United_Kingdom</option>
  553.  
  554. <option value="United_States">United_States</option>
  555.  
  556. <option value="United_States_Minor_Outlying_Islands">United_States_Minor_Outlying_Islands</option>
  557.  
  558. <option value="Uruguay">Uruguay</option>
  559.  
  560. <option value="Uzbekistan">Uzbekistan</option>
  561.  
  562. <option value="Vanuatu">Vanuatu</option>
  563.  
  564. <option value="Vatican">Vatican</option>
  565.  
  566. <option value="Venezuela">Venezuela</option>
  567.  
  568. <option value="Vietnam">Vietnam</option>
  569.  
  570. <option value="Virgin_Islands,_British">Virgin_Islands,_British</option>
  571.  
  572. <option value="Virgin_Islands,_U.S.">Virgin_Islands,_U.S.</option>
  573.  
  574. <option value="Wallis_and_Futuna">Wallis_and_Futuna</option>
  575.  
  576. <option value="Western_Sahara">Western_Sahara</option>
  577.  
  578. <option value="Yemen">Yemen</option>
  579.  
  580. <option value="Zambia">Zambia</option>
  581.  
  582. <option value="Zimbabwe">Zimbabwe</option>
  583.  
  584.  
  585.  
  586. </select></td>
  587.  
  588. </tr>
  589.  
  590. <tr>
  591.  
  592. <td>City:</td> <td><input type="text" name="city"></td>
  593.  
  594. </tr>
  595.  
  596. <tr>
  597.  
  598. <td>Nickname:</td> <td><input type="text" name="nickname"></td>
  599.  
  600. </tr>
  601.  
  602. <tr>
  603.  
  604. <td>Course:</td> <td><select name="desiredCourse">
  605.  
  606. <option value="summercourse">Summer Course</option>
  607.  
  608. <option value="internship">Internship</option>
  609.  
  610. <option value="phd">PHD</option>
  611.  
  612. <option value="others">Others</option>
  613.  
  614. </select></td>
  615.  
  616. </tr>
  617.  
  618. <tr>
  619.  
  620. <td>Type:</td> <td><select name="type">
  621.  
  622. <option value="summercourse">Summer Course</option>
  623.  
  624. <option value="internship">Internship</option>
  625.  
  626. <option value="phd">PHD</option>
  627.  
  628. <option value="others">Others</option>
  629.  
  630. </select></td>
  631.  
  632. </tr>
  633.  
  634. <tr>
  635.  
  636. <td>Comment:</td> <td><textarea rows="3" cols="25" name="comment"></textarea></td>
  637.  
  638. </tr>
  639.  
  640. <tr>
  641.  
  642. <td><input type="hidden" name="username" value="noreply@bhms.ch"></td>
  643.  
  644. </tr>
  645.  
  646. <tr>
  647.  
  648. <td><input type="hidden" name="password" value="CrmApiWeb123"></td>
  649.  
  650. </tr>
  651.  
  652. </table>
  653.  
  654. <br>
  655.  
  656. <input type="submit">
  657.  
  658. </form>
  659.  
  660. </font>
  661.  
  662.  
  663. <script type="text/javascript">
  664. $('#myForm').submit(function(e){
  665. e.preventDefault();
  666. console.log('submit');
  667. if(validateForm())
  668. {
  669. console.log('form submit');
  670. $.ajax({
  671. url:'http://bhms.online/app/web_api.php',
  672. type:'GET',
  673. data:$('#myForm').serialize(),
  674. success:function(data){
  675. console.log('response');
  676. alert(data);
  677. //whatever you wanna do after the form is successfully submitted
  678. }
  679. });
  680. }
  681. });
  682.  
  683.  
  684. //Initial form validation
  685. function validateForm() {
  686. //retrieving value from fields
  687. var firstName = document.forms["myForm"]["firstName"].value;
  688. var lastName = document.forms["myForm"]["lastName"].value;
  689. var getKnow = document.forms["myForm"]["getKnow"].value;
  690. var mobilePhone = document.forms["myForm"]["mobilePhone"].value;
  691. var email = document.forms["myForm"]["emailAddress"].value;
  692. var city = document.forms["myForm"]["city"].value;
  693. var country = document.forms["myForm"]["country"].value;
  694. var nickname = document.forms["myForm"]["nickname"].value;
  695. var username = document.forms["myForm"]["username"].value;
  696. var password = document.forms["myForm"]["password"].value;
  697.  
  698. //check whether fields are filled out
  699. if ( firstName && lastName && getKnow && mobilePhone &&
  700. email && city && country && nickname &&
  701. username && password) {
  702. return true;
  703. }
  704. else
  705. {
  706. alert("Please fill in all fields");
  707. return false;
  708. }
  709. return true;
  710. }
  711. </script>
  712. </body>
  713. </html>
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