<?php
function cleanEI($s){ // EI = EmailInjection
  return str_ireplace(Array("\r\n","\r","\n","\t","%0A","%0D","%08","%09","bcc:","cc:"),'',$s);
}
function bindAndPreventEI(){
  $a = func_get_args();
  $cn = count($a);
  for($i=0;$i<$cn;++$i){
    Global ${$a[$i]};
    ${$a[$i]} = cleanEI($_POST[$a[$i]]);
  }
}
if($_SERVER['REQUEST_METHOD'] === 'POST'){
  // Check for Email Injection and bind to script
  bindAndPreventEI('name','email','phone1','phone2','call','referral','message');
  $email = urldecode($email);
  $services = (count($_POST['Services']) > 0)? cleanEI(implode(', ', $_POST['Services'])) : '';
  $formcontent = "
From: $name
Email: $email
Landline: $phone1
Mobile: $phone2
Preferred Call: $call
Services: $services
Referral: $referral
Message: $message
";
  echo '<pre>';
  echo $formcontent;
  exit;

}

$contactForm = <<<FORM
<form action="" method="post">
<table width="410" border="0">
  <tr>
    <td colspan="4">
      <p><strong>Name</strong></p><br />
    </td>
    <td colspan="2">
      <input type="text" name="name" />
    </td>
  </tr>
  <tr>
    <td colspan="4">
      <strong>Email</strong>
    </td>
    <td colspan="2"><input type="text" name="email" />
    </td>
  </tr>
  <tr>
    <td height="20" colspan="4">
      <strong>Landline Telephone</strong><br />
    </td>
    <td height="20" colspan="2">
      <input type="text" name="phone1" />
    </td>
  </tr>
  <tr>
    <td height="22" colspan="4">
      <p><strong>Mobile Telephone</strong><br /></p>
    </td>
    <td colspan="2">
      <input type="text" name="phone2" />
    </td>
  </tr>
  <tr>
    <td height="38" colspan="4">
      <strong>Preferred Contact</strong>
    </td>
    <td width="84">
      Landline: <input type="radio" value="Landline" name="call" checked="checked" />
    </td>
    <td width="103">
      Mobile: <input type="radio" value="Mobile" name="call" />
    </td>
  </tr>
  <tr>
    <td height="38" colspan="4">
      <strong>How Did You Hear About Us</strong>
    </td>
    <td colspan="2">
      <select name="referral" size="1">
        <option value="Low">Low</option>
        <option value="Normal">Normal</option>
        <option value="High">High</option>
        <option value="Emergency">Emergency</option>
      </select>
    </td>
  </tr>
  <tr>
    <td height="24" colspan="4">
      <strong>Our services</strong>
    </td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td height="20" colspan="3" align="right">
      Landline: <input type="checkbox" value="Landline" name="Services[]" />
    </td>
    <td height="20" align="right">&nbsp;</td>
    <td>
      Mobile: <input type="checkbox" value="Mobile" name="Services[]" />
    </td>
    <td>
      Service3: <input type="checkbox" value="Service3" name="Services[]" />
    </td>
  </tr>
  <tr>
    <td height="20" colspan="3" align="right">
      Service7: <input type="checkbox" value="Service7" name="Services[]" />
    </td>
    <td height="20" align="right">&nbsp;</td>
    <td>
      Service8: <input type="checkbox" value="Service8" name="Services[]" />
    </td>
    <td>
      Service9: <input type="checkbox" value="Service9" name="Services[]" />
    </td>
  </tr>
  <tr>
    <td height="20" colspan="3" align="right">
      Service4: <input type="checkbox" value="Service4" name="Services[]" />
    </td>
    <td width="27" align="right">&nbsp;</td>
    <td>
      Service5: <input type="checkbox" value="Service5" name="Services[]" />
    </td>
    <td>
      Service6: <input type="checkbox" value="Service6" name="Services[]" />
    </td>
  </tr>
  <tr>
    <td height="20" colspan="4">
      <strong>Message</strong>
    </td>
    <td>&nbsp;</td>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td height="20" colspan="6">
      <textarea name="message" rows="6" cols="55"></textarea>
    </td>
  </tr>
  <tr>
    <td width="59" height="20">&nbsp;</td>
    <td width="1">&nbsp;</td>
    <td width="110">&nbsp;</td>
    <td height="20">&nbsp;</td>
    <td height="20">&nbsp;</td>
    <td height="20"><input type="submit" value="Send" />      <input type="reset" value="Clear" />
    </td>
  </tr>
</table>
<p><br />
</p>
</form>
FORM;

echo $contactForm;