API tools faq
paste
Advertisement
Guest User

Untitled

a guest
Apr 9th, 2017
122
0
Never
Add comment
Not a member of Pastebin yet? Sign Up, it unlocks many cool features!
text 23.35 KB | None | 0 0
raw download clone embed print report
  1. <!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
  2. <html xmlns="http://www.w3.org/1999/xhtml" dir="rtl" lang="ar-su" xml:lang="ar-su">
  3. <head>
  4. <meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
  5. <meta http-equiv="Content-Language" content="en-us" />
  6. <title>استمارة التكفل</title>
  7. <link rel="stylesheet" href="contact.css" type="text/css" />
  8. </head>
  9.  
  10. <body>
  11. <script language="javascript">
  12. function fncSubmit()
  13. {
  14. if(document.form1.chk1.checked == false)
  15. {
  16. alert('Please Click Checkbox 1 ');
  17. return false;
  18. }
  19. if(document.form1.chk2.checked == false)
  20. {
  21. alert('Please Click Checkbox 2 ');
  22. return false;
  23. }
  24. document.form1.submit();
  25. }
  26. </script>
  27. <div id="container">
  28.  
  29. <div id="header">
  30. <div class="top"></div>
  31. <div class="spacer"></div>
  32. <div class="logo">
  33. <?php
  34. $config_file = "include/config.php";
  35. if (file_exists($config_file))
  36. {
  37. $fd = fopen($config_file, 'rb');
  38. $restore_query = fread($fd, filesize($config_file));
  39. // echo "EXISTS";
  40. // echo $restore_query;
  41.  
  42. $mystring1 = $restore_query;
  43. $findme1 = '$l'; // find position of logo_url
  44. $pos1 = strpos($mystring1, $findme1);
  45. // echo $pos1;
  46.  
  47. $mystring2 = $restore_query;
  48. $findme2 = '$s'; // find position of site_url
  49. $pos2 = strpos($mystring2, $findme2);
  50. // echo $pos2;
  51.  
  52. $dif = $pos2 - $pos1;
  53. // echo $dif; // diffference (b/w site_url and logo_url) is length
  54.  
  55. $difference_substring = substr($restore_query, $pos1, $dif);
  56. // echo $difference_substring;
  57.  
  58. $mystring3 = $difference_substring;
  59. $findme3 = 'h'; // find position of http
  60. $pos3 = strpos($mystring3, $findme3);
  61. // echo $pos3;
  62.  
  63. $mystring4 = $difference_substring;
  64. $findme4 = ';'; // find position of colon
  65. $pos4 = strpos($mystring4, $findme4);
  66. // echo $pos4;
  67.  
  68. $dif1 = $pos4 - $pos3;
  69. // echo $dif1; // diffference (b/w colon and http) is length
  70.  
  71. $correct_dif = $dif1 - 1;
  72.  
  73. $difference1_substring = substr($difference_substring, $pos3, $correct_dif);
  74. // echo $difference1_substring;
  75.  
  76. echo "&nbsp;&nbsp;
  77. <img src='$difference1_substring' />
  78. &nbsp;&nbsp;&nbsp;&nbsp;<font size='4' face='arial' color=#000000><b>مكتب مؤسسة العين في المانيا</b></font>";
  79.  
  80. fclose($fd);
  81. }
  82. else
  83. {
  84. // echo "DOES NOT EXIST";
  85. $error = 'SQL file does not exist: ' . $config_file;
  86. }
  87. ?>
  88. </div>
  89.  
  90. <div id="inner-container" class="clearfix"> <!-- inner-container -->
  91.  
  92. <div id="content">
  93.  
  94. <div style="margin-right:11em">
  95.  
  96. <?php
  97. //Sample Database Connection Syntax for PHP and MySQL.
  98. //Connect To Database
  99. include('include/config.php');
  100. //$hostname="put your host name here, for example, p41mysqladmin.secureserver.net, or localhost";
  101. //$username="put your user name for the database";
  102. //$password="put your host name for the database";
  103. $usertable="contacts";
  104. $field1 = "last";
  105. $field2 = "first";
  106. $field70 = "k1";
  107. $field71 = "k2";
  108. $field72 = "k3";
  109. $field73 = "k4";
  110. $field3 = "middle";
  111. $field4 = "dob";
  112. $field5 = "address";
  113. $field6 = "city";
  114. $field7 = "phone";
  115. $field8 = "cell_phone";
  116. $field9 = "first_contact";
  117. $field10 = "first_relation";
  118. $field11 = "first_phone";
  119. $field12 = "second_contact";
  120. $field13 = "second_relation";
  121. $field14 = "second_phone";
  122. $field15 = "physician";
  123. $field16 = "phy_phone";
  124. $field17 = "medical_note";
  125. $field18 = "state";
  126. $field19 = "zip";
  127. $field20 = "email";
  128. $field97 = "id";
  129. // Alternative to include statement, $con = mysql_connect("$hostname", "$username", "$password");
  130. // Alternative to include statement, mysql_select_db('put name in these single quotes, or variable without these quotes', $con);
  131. $con = mysql_connect("$dbhost", "$dbuser", "$dbpass");
  132. mysql_select_db($dbname, $con);
  133.  
  134. if (!$con)
  135. {
  136. die('Could not connect: ' . mysql_error());
  137. }
  138.  
  139. if (isset($_REQUEST['first'])) // End of if structure where it checks if form is submitted.
  140. {
  141. $submet_email = $_REQUEST['email'];
  142. $querya = "SELECT * FROM $usertable";
  143. $queryb = "SELECT * FROM $usertable WHERE email = '$submet_email'";
  144.  
  145. $resulta = mysql_query($querya);
  146. $resultb = mysql_query($queryb);
  147.  
  148. if($resulta) // This if checks, if there are previously entered any records, or it is first time.
  149. {
  150. while($rowb = mysql_fetch_array($resultb)) //If there is even one record, the if and while parts would execute, it further compares the email
  151. {
  152. //echo "while part executed";
  153. $submitted_email = $submet_email;
  154. $email = $rowb["$field20"];
  155. if ($email == $submitted_email)
  156. {
  157. $capture_email = $email;
  158. }
  159. } // End of while loop
  160. $blank = "";
  161.  
  162. if ($capture_email == $submet_email && $capture_email != $blank)
  163. {
  164. $sub_last = $_REQUEST['last'];
  165. $sub_first = $_REQUEST['first'];
  166. $sub_k1 = $_REQUEST['k1'];
  167. $sub_k2 = $_REQUEST['k2'];
  168. $sub_k3 = $_REQUEST['k3'];
  169. $sub_k4 = $_REQUEST['k4'];
  170. $sub_middle = $_REQUEST['middle'];
  171. $sub_dob = $_REQUEST['dd'].".".$_REQUEST['mm'].".".$_REQUEST['yyyy'];
  172. $sub_address = $_REQUEST['address'];
  173. $sub_city = $_REQUEST['city'];
  174. $sub_state = $_REQUEST['state'];
  175. $sub_zip = $_REQUEST['zip'];
  176. $sub_phone = $_REQUEST['phone'];
  177. $sub_cell_phone = $_REQUEST['cell_phone'];
  178. $sub_first_contact = $_REQUEST['first_contact'];
  179. $sub_first_relation = $_REQUEST['first_relation'];
  180. $sub_first_phone = $_REQUEST['first_phone'];
  181. $sub_second_contact = $_REQUEST['second_contact'];
  182. $sub_second_relation = $_REQUEST['second_relation'];
  183. $sub_second_phone = $_REQUEST['second_phone'];
  184. $sub_physician = $_REQUEST['physician'];
  185. $sub_phy_phone = $_REQUEST['phy_phone'];
  186. $sub_medical_note = $_REQUEST['medical_note'];
  187. $dat = date("Y-m-d");
  188. $tim = date("H:m:s");
  189. $timstamp = $dat." ".$tim;
  190. $eyep = $_SERVER['REMOTE_ADDR'];
  191. $query1 = "UPDATE contacts SET last = '$sub_last', first = '$sub_first', k1 = '$sub_k1', k2 = '$sub_k2', k3 = '$sub_k3', k4 = '$sub_k4', middle = '$sub_middle'
  192. , email = '$submitted_email', dob = '$sub_dob', address = '$sub_address', city = '$sub_city'
  193. , state = '$sub_state', zip = '$sub_zip', phone = '$sub_phone', cell_phone = '$sub_cell_phone'
  194. , first_contact = '$sub_first_contact', first_relation = '$sub_first_relation', first_phone = '$sub_first_phone'
  195. , second_contact = '$sub_second_contact', second_relation = '$sub_second_relation', second_phone = '$sub_second_phone'
  196. , physician = '$sub_physician', phy_phone = '$sub_phy_phone', medical_note = '$sub_medical_note', date = '$timstamp'
  197. , ip = '$eyep' WHERE email = '$submet_email'";
  198. $result1 = mysql_query($query1);
  199. if($result1)
  200. {
  201. echo "<br />You have successfully deleted <b>".$trans_fname." ".$trans_lname."</b>'s information.<br /><br />
  202. <center>
  203. <form>
  204. <input type='button' value='Close this window' onClick='window.close()'>
  205. </form>
  206. </center>
  207. <br />
  208. ";
  209. }
  210.  
  211. } // End of internal if structure with comparison operator
  212.  
  213. else
  214. {
  215. // echo "else part executed";
  216. $testing = $_REQUEST['first'];
  217. // echo $testing;
  218. $dat = date("Y-m-d");
  219. $tim = date("H:m:s");
  220. $timstamp = $dat." ".$tim;
  221. $eyep = $_SERVER['REMOTE_ADDR'];
  222. $query2="INSERT INTO $usertable (last, first, k1, k2, k3, k4, middle, email, dob, address, city, phone, cell_phone, first_contact,
  223. first_relation, first_phone, second_contact, second_relation, second_phone, physician, phy_phone, medical_note, state,
  224. zip, date, ip)
  225. VALUES ('$_REQUEST[last]','$_REQUEST[first]','$_REQUEST[k1]','$_REQUEST[k2]','$_REQUEST[k3]','$_REQUEST[k4]','$_REQUEST[middle]','$_REQUEST[email]',
  226. '$_REQUEST[dd].$_REQUEST[mm].$_REQUEST[yyyy]','$_REQUEST[address]','$_REQUEST[city]','$_REQUEST[phone]',
  227. '$_REQUEST[cell_phone]','$_REQUEST[first_contact]','$_REQUEST[first_relation]','$_REQUEST[first_phone]',
  228. '$_REQUEST[second_contact]','$_REQUEST[second_relation]','$_REQUEST[second_phone]','$_REQUEST[physician]',
  229. '$_REQUEST[phy_phone]','$_REQUEST[medical_note]','$_REQUEST[state]','$_REQUEST[zip]','$timstamp','$eyep')";
  230. $result2 = mysql_query($query2);
  231. if($result2)
  232. {
  233. echo "<br /> شكرا لكم لقم قمنا الان باستلام الاستمارة الخاصة بتكفل اليتم وسوف يقوم احد موظفين مؤسسة العين في المانيا بالتواصل معكم.<br /><br />
  234. <center>
  235. <form>
  236. <input type='button' value='Close this window' onClick='window.close()'>
  237. </form>
  238. </center>
  239. <br />
  240. ";
  241. }
  242. else
  243. {
  244. // echo "query failed";
  245. }
  246. } // End of else structure connected with if comparisor operator.
  247. } // End of if structure where it checks if it is first time.
  248.  
  249. else // Start of else structure connected with if where it checks if it is first time.
  250. {
  251. // echo "This part executed";
  252. $dat = date("Y-m-d");
  253. $tim = date("H:m:s");
  254. $timstamp = $dat." ".$tim;
  255. // echo $timstamp;
  256. $eyep = $_SERVER['REMOTE_ADDR'];
  257. $query2="INSERT INTO contacts (last, first, k1, k2, k3, k4, middle, email, dob, address, city, phone, cell_phone, first_contact, k1,
  258. first_relation, first_phone, second_contact, second_relation, second_phone, physician, phy_phone, medical_note, state,
  259. zip, date, ip)
  260. VALUES ('$_REQUEST[last]','$_REQUEST[first]','$_REQUEST[k1]','$_REQUEST[k2]','$_REQUEST[k3]','$_REQUEST[k4]','$_REQUEST[middle]','$_REQUEST[email]',
  261. '$_REQUEST[dd].$_REQUEST[mm].$_REQUEST[yyyy]','$_REQUEST[address]','$_REQUEST[city]','$_REQUEST[phone]',
  262. '$_REQUEST[cell_phone]','$_REQUEST[first_contact]','$_REQUEST[first_relation]','$_REQUEST[first_phone]',
  263. '$_REQUEST[second_contact]','$_REQUEST[second_relation]','$_REQUEST[second_phone]','$_REQUEST[physician]',
  264. '$_REQUEST[phy_phone]','$_REQUEST[medical_note]','$_REQUEST[state]','$_REQUEST[zip]','$timstamp','$eyep')";
  265. $result2 = mysql_query($query2);
  266. if($result2)
  267. {
  268. $first = $_REQUEST['first'];
  269. $last = $_REQUEST['last'];
  270. echo "<b>".$first." ".$last."</b>, Thank You for saving your emergency contact information.<br /><br />
  271. <!--
  272. <br /><br /><center>
  273. <form>
  274. <input type='button' value='Close this window' onClick='window.close()'>
  275. </form>
  276. </center>
  277. <br />
  278. --> ";
  279. }
  280. } // End of else structure connected with if where it checks if it is first time.
  281.  
  282. mysql_close($con);
  283. } // End of if structure where it checks if form is submitted.
  284. else
  285. {
  286. echo "
  287. <font size='3' face='arial' color=#000000><b> </b></font><br />";
  288. echo "<form action='index.php' method='post' onSubmit="JavaScript:return fncSubmit();>
  289. </tr>
  290. </table>
  291. <br /><font size='4' face='arial' color=#000000><b>معلومات الكفيل يرجى ملئ جميع الحقول</b></font><br />
  292. <table border='10' bgcolor='#FFFFFF'>
  293. <tr>
  294. <td><font color=#000000 size='4' face='arial'>الاسم الكامل:</font></td><td><input type='text' name='first' size='4' style='width: 11em' /></td>
  295. <td><font color=#000000 size='4' face='arial'>اللقب:</font></td><td><input type='text' name='last' size='4' style='width: 6em' /></td>
  296. </tr>
  297. <tr>
  298. <td><font color=#000000 size='4' face='arial'>تاريخ الميلاد:</font></td>
  299. <td>
  300. <select name='dd'>
  301. <option SELECTED value='01'>01
  302. <option value='02'>02
  303. <option value='03'>03
  304. <option value='04'>04
  305. <option value='05'>05
  306. <option value='06'>06
  307. <option value='07'>07
  308. <option value='08'>08
  309. <option value='09'>09
  310. <option value='10'>10
  311. <option value='11'>11
  312. <option value='12'>12
  313. <option value='13'>13
  314. <option value='14'>14
  315. <option value='15'>15
  316. <option value='16'>16
  317. <option value='17'>17
  318. <option value='18'>18
  319. <option value='19'>18
  320. <option value='20'>20
  321. <option value='21'>21
  322. <option value='22'>22
  323. <option value='23'>23
  324. <option value='24'>24
  325. <option value='25'>25
  326. <option value='26'>26
  327. <option value='27'>27
  328. <option value='28'>28
  329. <option value='29'>29
  330. <option value='30'>30
  331. <option value='31'>31
  332. </select>
  333.  
  334. <select name='mm'>
  335. <option SELECTED value='01'>01
  336. <option value='02'>02
  337. <option value='03'>03
  338. <option value='04'>04
  339. <option value='05'>05
  340. <option value='06'>06
  341. <option value='07'>07
  342. <option value='08'>08
  343. <option value='09'>09
  344. <option value='10'>10
  345. <option value='11'>11
  346. <option value='12'>12
  347. </select>
  348.  
  349. <select name='yyyy'>
  350. <option SELECTED value='1900'>1900
  351. <option value='1901'>1901
  352. <option value='1902'>1902
  353. <option value='1903'>1903
  354. <option value='1904'>1904
  355. <option value='1905'>1905
  356. <option value='1906'>1906
  357. <option value='1907'>1907
  358. <option value='1908'>1908
  359. <option value='1909'>1909
  360. <option value='1910'>1910
  361. <option value='1911'>1911
  362. <option value='1912'>1912
  363. <option value='1913'>1913
  364. <option value='1914'>1914
  365. <option value='1915'>1915
  366. <option value='1916'>1916
  367. <option value='1917'>1917
  368. <option value='1918'>1918
  369. <option value='1919'>1919
  370. <option value='1920'>1920
  371. <option value='1921'>1921
  372. <option value='1922'>1922
  373. <option value='1923'>1923
  374. <option value='1924'>1924
  375. <option value='1925'>1925
  376. <option value='1926'>1926
  377. <option value='1927'>1927
  378. <option value='1928'>1928
  379. <option value='1929'>1929
  380. <option value='1930'>1930
  381. <option value='1931'>1931
  382. <option value='1932'>1932
  383. <option value='1933'>1933
  384. <option value='1934'>1934
  385. <option value='1935'>1935
  386. <option value='1936'>1936
  387. <option value='1937'>1937
  388. <option value='1938'>1938
  389. <option value='1939'>1939
  390. <option value='1940'>1940
  391. <option value='1941'>1941
  392. <option value='1942'>1942
  393. <option value='1943'>1943
  394. <option value='1944'>1944
  395. <option value='1945'>1945
  396. <option value='1946'>1946
  397. <option value='1947'>1947
  398. <option value='1948'>1948
  399. <option value='1949'>1949
  400. <option value='1950'>1950
  401. <option value='1951'>1951
  402. <option value='1952'>1952
  403. <option value='1953'>1953
  404. <option value='1954'>1954
  405. <option value='1955'>1955
  406. <option value='1956'>1956
  407. <option value='1957'>1957
  408. <option value='1958'>1958
  409. <option value='1959'>1959
  410. <option value='1960'>1960
  411. <option value='1961'>1961
  412. <option value='1962'>1962
  413. <option value='1963'>1963
  414. <option value='1964'>1964
  415. <option value='1965'>1965
  416. <option value='1966'>1966
  417. <option value='1967'>1967
  418. <option value='1968'>1968
  419. <option value='1969'>1969
  420. <option value='1970'>1970
  421. <option value='1971'>1971
  422. <option value='1972'>1972
  423. <option value='1973'>1973
  424. <option value='1974'>1974
  425. <option value='1975'>1975
  426. <option value='1976'>1976
  427. <option value='1977'>1977
  428. <option value='1978'>1978
  429. <option value='1979'>1979
  430. <option value='1980'>1980
  431. <option value='1981'>1981
  432. <option value='1982'>1982
  433. <option value='1983'>1983
  434. <option value='1984'>1984
  435. <option value='1985'>1985
  436. <option value='1986'>1986
  437. <option value='1987'>1987
  438. <option value='1988'>1988
  439. <option value='1989'>1989
  440. <option value='1990'>1990
  441. <option value='1991'>1991
  442. <option value='1992'>1992
  443. <option value='1993'>1993
  444. <option value='1994'>1994
  445. <option value='1995'>1995
  446. <option value='1996'>1996
  447. <option value='1997'>1997
  448. <option value='1998'>1998
  449. <option value='1999'>1999
  450. <option value='2000'>2000
  451. <option value='2001'>2001
  452. <option value='2002'>2002
  453. <option value='2003'>2003
  454. <option value='2004'>2004
  455. <option value='2005'>2005
  456. <option value='2006'>2006
  457. <option value='2007'>2007
  458. <option value='2008'>2008
  459. <option value='2009'>2009
  460. </select>
  461. </tr>
  462. <td><font color=#000000 size='4' face='arial'>البريد الالكتروني:</font></td><td><input width='2' type='text' name='email' /></td>
  463. <td></td>
  464. <td></td>
  465. </tr>
  466. </table>
  467. <br /><font size='4' face='arial' color=#000000><b>العنوان</b></font><br />
  468. <table border='10' bgcolor='#FFFFFF'>
  469. <tr>
  470. <tr><td><font color=#000000 size='4' face='arial'>الرمز البريدي:</font></td><td><input type='text' name='zip' size='15' style='width: 6em' /></td>
  471. <td><font color=#000000 size='4' face='arial'>المدينة:</font></td><td><input type='text' name='city' size='15' style='width: 6em' /></td>
  472. <td><font color=#000000 size='4' face='arial'>البلد:</font></td><td><input type='text' name='physician' size='15' style='width: 6em' /></td>
  473. </tr>
  474. <tr>
  475. <td><font color=#000000 size='4' face='arial'>رقم الهاتف:</font></td><td><input type='text' name='phone' size='15' style='width: 6em' /></td>
  476. </table>
  477. <br /><font size='4' face='arial' color=#000000><b>انواع الكفالة</b></font><br />
  478. <table border='10' bgcolor='#FFFFFF'>
  479. <tr>
  480. <td align='right'><font color=#000000 size='4' face='arial'>الكفالة الاعتيادية 68 يورو شهريا:&nbsp;&nbsp;</font></td>
  481. <td>
  482. <select name='cell_phone'>
  483. <option value='0'>العدد
  484. <option value='01'>1
  485. <option value='02'>2
  486. <option value='03'>3
  487. <option value='04'>4
  488. <option value='05'>5
  489.  
  490. </td>
  491. <tr>
  492. <td align='right'><font color=#000000 size='4' face='arial'>كفالة يتامى ذوي الاحتياجات الخاصة 82 يورو شهريا:&nbsp;&nbsp;</font></td>
  493. <td>
  494. <select name='first_contact'>
  495. <option value='0'>العدد
  496. <option value='01'>1
  497. <option value='02'>2
  498. <option value='03'>3
  499. <option value='04'>4
  500. <option value='05'>5
  501.  
  502. </td>
  503. <tr>
  504. <td align='right'><font color=#000000 size='4' face='arial'>كفالة يتامى ضحايا الارهاب 82 يورو شهريا:&nbsp;&nbsp;</font></td>
  505. <td>
  506. <select name='first_relation'>
  507. <option value='0'>العدد
  508. <option value='01'>1
  509. <option value='02'>2
  510. <option value='03'>3
  511. <option value='04'>4
  512. <option value='05'>5
  513.  
  514. </td>
  515. <tr>
  516. <td align='right'><font color=#000000 size='4' face='arial'>كفالة يتامى المتفوقين دراسيا 97 يورو شهريا:&nbsp;&nbsp;</font></td>
  517. <td>
  518. <select name='first_phone'>
  519. <option value='0'>العدد
  520. <option value='01'>1
  521. <option value='02'>2
  522. <option value='03'>3
  523. <option value='04'>4
  524. <option value='05'>5
  525.  
  526. </td>
  527. </table>
  528. <br /><font size='4' face='arial' color=#19a1bf><b>طريقة الدفع</b></font><br />
  529. <table border='10' bgcolor='#FFFFFF'>
  530. <tr>
  531. <td align='right'><font color=#000000 size='4' face='arial'>&nbsp;&nbsp;</font></td>
  532. <td>
  533. <select name='second_contact'>
  534. <option value='-'>شهريا
  535. <option value='نعم'>نعم
  536. <option value='لا'>لا
  537.  
  538. </td>
  539. <tr>
  540. <td align='right'><font color=#000000 size='4' face='arial'>&nbsp;&nbsp;</font></td>
  541. <td>
  542. <select name='second_relation'>
  543. <option value='-'>فصليا
  544. <option value='نعم'>نعم
  545. <option value='لا'>لا
  546.  
  547. </td>
  548. <tr>
  549. <td align='right'><font color=#000000 size='4' face='arial'>&nbsp;&nbsp;</font></td>
  550. <td>
  551. <select name='second_phone'>
  552. <option value='-'>سنويا
  553. <option value='نعم'>نعم
  554. <option value='لا'>لا
  555.  
  556. </table>
  557. <br /><font size='4' face='arial' color=#19a1bf><b> مكان الدفع ملاحظة (يرجى كتابة أسم البلد أو المحافظة الذي ترومون الدفع فيه) </b></font><br />
  558. <table border='10' bgcolor='#FFFFFF'>
  559. <tr>
  560. <td><font color=#000000 size='4' face='arial'>يرجى الكتابة هنا:</font></td><td><input type='text' name='k1' size='4' style='width: 11em' /></td>
  561. </table>
  562.  
  563. </td>
  564. </tr>
  565.  
  566. </table>
  567. <br /><font size='4' face='arial' color=#19a1bf><b>حال رغبتكم دفع مبلغ لليتيم شهريا اكثر من المبلغ اعلاه يرجى كتابة المبلغ في الحقل ادناه </b></font><br />
  568. <table border='10' bgcolor='#FFFFFF'>
  569. <tr>
  570. <td><font color=#000000 size='4' face='arial'>يرجى كتابة المبلغ هنا:</font></td><td><input type='text' name='k3' size='4' style='width: 11em' /></td>
  571. </table>
  572. <br /><font size='4' face='arial' color=#19a1bf><b>هل الكفالة</b></font><br />
  573. <table border='10' bgcolor='#FFFFFF'>
  574. <tr>
  575. <td align='right'><font color=#000000 size='4' face='arial'>&nbsp;&nbsp;</font></td>
  576. <td>
  577. <select name='k2'>
  578. <option value='لاول مرة'>لاول مرة
  579. <option value='إضافة يتيم'>إضافة يتيم
  580. <option value='إعادة كفالة'>إعادة كفالة
  581.  
  582. </td>
  583.  
  584. </table>
  585. <table border='10' bgcolor='#FFFFFF'>
  586. <tr><td valign='top'><font color=#000000 size='3' face='arial'>هل لديك اي مشكلة او معلومات اضافية لم تكن موجودة في الحقول السابقة يرجى كتابة المعلومات الاضاقية داخل هذا المربع وسوف يرد على حضراتكم موضف قسم الاعلام في مؤسسة العين .</font><br /><textarea name='medical_note' rows='8' cols='85'></textarea></td></tr>
  587. </table><br />
  588. </tr>
  589. <tr>
  590. </table>
  591. <br />
  592. <input name="chk1" type="checkbox" id="chk1" value="Y"><font size='4' face='arial' color=#ff0000><b> ان هذا الطلب يعتبر التزامآ تشريفيآ ادبيآ بين الكفيل واليتيم لذا يرحى مراعاة فقرات دور الكفيل اعلاه مع الدعاء لكم بحسن التوفيق </b></font><br />
  593. <table border='10' bgcolor='#FFFFFF'>
  594. <tr>
  595. </tr>
  596. <table border='10' bgcolor='#FFFFFF'>
  597. <input name="btnSubmit" type="submit" value='ارسال الاستمارة' />
  598. </table><br />
  599. </form>";
  600.  
  601. }
  602. ?>
  603. </div>
  604.  
  605. </div> <!-- EOF: CONTENT FRAME -->
  606.  
  607. </div> <!-- EOF: inner-container -->
  608. <div id="copyright">
  609.  
  610. <div class="left">Copyright &copy; karrar-Hayder </div>
  611.  
  612. </div> <!-- EOF: CONTAINER -->
  613. <!-- EOF: FOOTER INCLUDE -->
  614. </body>
  615. </html>
Advertisement
Add Comment
Please, Sign In to add comment
Advertisement
Public Pastes
Advertisement
We use cookies for various purposes including analytics. By continuing to use Pastebin, you agree to our use of cookies as described in the Cookies Policy.  OK, I Understand
Not a member of Pastebin yet?
Sign Up, it unlocks many cool features!