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Current File : /home/meir5web/public_html/f/form_inc_yoni_backup.php
<div align="center">

                      <br>

                  <table width="410" border="1" align="center" cellpadding="0" cellspacing="2" bordercolor="#FF0000" bgcolor="#FFFFFF">
                    <tr>
                      <td><div style="padding:4px;"> <p align="center" class="style5">                          FRANCE ET SUISSE<br>
                        Pour recevoir automatiquement le reçu CERFA correspondant à votre don, envoyez vos chèques directement en nos bureaux de France et de Suisse. 
                        Les dons payés en carte de crédit arrivent directement en Israël et ne peuvent pas être déductibles des impôts français ou suisses. </p></div>                              </td>
                          </tr>
                  </table>
                </div>
				<br>
                    <br>
                    <form action="donation_send_f.php" method=POST name="validation" id="validation"
            ONSUBMIT="return  Form_Validator(this)">
                      <div align="center"><a name="form"></a><span class="textRed">* L'information requise</span><br>
                      </div>
                      <table width="400" border="0" align="center" cellpadding="0" cellspacing="0">
                        <tr>
                          <td><div align="center"><span class="text1"><img src="images/grey_frame_top.gif" width="395" height="11" hspace="0" vspace="0" border="0"></span>
                          </div>
                            <table width="400" border="0" cellpadding="2" cellspacing="2" class="text1">
                              
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="text1"><div align="right" class="headerNewsHP"> Titre : </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><select name=Title class="headerNewsHP">
                                    <option>Mr </option>
                                    <option>Mrs </option>
                                    <option>Ms </option>
                                    <option>Dr </option>
                                    <option>Rabbi </option>
                                    <option>Cantor</option>
                                  </select>
                                    <b>
                                    <input name="MPreffers" type="hidden"  id="MPreffers" 
							value="<? echo $MPreffers; ?>" >
							<input name="MPbanner" type="hidden"  id="MPbanner" 
							value="<? echo $MPbanner; ?>" >
                                  </b> </td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Prénom nom: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="Name" type=text class="headerNewsHP" value="<?php echo $_COOKIE['Name'] ?>">
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> E-mail:</div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="email" type=text class="headerNewsHP" onChange="javascript:this.value=this.value.toLowerCase();" value="<?php echo $_COOKIE['email'] ?>">
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> Adresse: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input  name="Address" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['Address'] ?>" maxlength="50">
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> Localité: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input  name="City" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['City'] ?>" maxlength="50">
                                </b></td>
                              </tr>
                              
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> Code postal: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="Zip" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['Zip'] ?>" size="10" maxlength="10">
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> Pays: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="Country" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['Country'] ?>" size="10" maxlength="20">
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> Téléphone: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="Phone" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['Phone'] ?>" size="10" maxlength="20">
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> N&deg; identité (pour les israéliens):</div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="ICard" type="text" class="headerNewsHP" value="<?php echo $_COOKIE['ICard'] ?>" maxlength="50">
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Modalité 
                              de paiement: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <select class="headerNewsHP" name="Payment_method" size="1" >
                                    <option>Modalit&eacute; de paiement</option>
                              <option>Diners</option>
                              <option>Visa</option>
                              <option>American Express</option>
                              <option>Mastercard</option>
                                  </select>
                                </b></td>
                              </tr>
                              <tr>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Numéro 
                              de carte: </div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input type="text" name="Card_Number" maxlength="16" class="headerNewsHP">
                                </b></td>
                              </tr>
                              <tr>
                                <td bgcolor="#F3F3F3" class="headerNewsHP"><div align="right"><span class="textRed">*</span>Code de validation de carte: <br>
                                  <a href="#9"><span class="textsmall" onClick="MM_openBrWindow('http://www.meirpanim.org/donations/cvv.htm','cvv','status=yes,width=450,height=500')">Ce qui est celui?</span></a></div></td>
                                <td bgcolor="#F3F3F3" class="headerNewsHP"><b>
                                  <input name="Card_Security_Code" type="text" class="headerNewsHP" size="4" maxlength="4">
                                </b></td>
                              </tr>
                              <tr bgcolor="#F3F3F3">
                                <td width="50%" class="headerNewsHP"><div align="right"> <span class="textRed">*</span>Date limite de validité: Mois </div></td>
                                <td width="50%" class="headerNewsHP"><B>
                                  <SELECT NAME="expmonth" SIZE="1" CLASS="headerNewsHP">
                                    <OPTION></OPTION>
                                    <OPTION>01</OPTION>
                                    <OPTION>02</OPTION>
                                    <OPTION>03</OPTION>
                                    <OPTION>04</OPTION>
                                    <OPTION>05</OPTION>
                                    <OPTION>06</OPTION>
                                    <OPTION>07</OPTION>
                                    <OPTION>08</OPTION>
                                    <OPTION>09</OPTION>
                                    <OPTION>10</OPTION>
                                    <OPTION>11</OPTION>
                                    <OPTION>12</OPTION>
                                  </SELECT>
                                  </B>&nbsp;<span class="textRed">*</span>Année&nbsp; <B>
                                  <select size="1" name="expyear" class="headerNewsHP">
<option></option>
<?
$year = date('Y') ;
for ( $counter = 1; $counter <= 11; $counter += 1) {
echo "<option>$year</option>";
$year = $year+1 ;	
}
?>
</select>
                                </B></td>
                              </tr>
                              <tr bgcolor="#F3F3F3">
                                <td colspan="2" class="text1"><div align="center"><img src="images/36_payments_top.gif" width="382" height="15"></div></td>
                              </tr>
<?php if ( $_GET['occasion'] == "pesach" )
						  {  ?>
						  <tr bgcolor="#F3F3F3"> 
                          <td colspan="2" class="text"> <div align="center" class="headerNewsHP"><b><font size="2">$36.00 will buy a complete Seder Meal for a needy person</font></b></div></td>
                        </tr>
                        <TR BGCOLOR="#cce0ff"> 
                          <TD colspan="2" bgcolor="#F3F3F3" CLASS="text"> <div align="center">&nbsp;
                            <INPUT NAME="Number_of_payments" TYPE="hidden" CLASS="headerNewsHP" ID="months" ONCHANGE="js:calcTotal()" value="1" SIZE="2" MAXLENGTH="3"> <br>
                         <span class="headerNewsHP">TO MAKE A MONTHLY DONATION PLE
                         <select id="payment" name="Amount_of_payment" onChange="js:calcTotal()" class="headerNewsHP">
                           <option value="" selected></option>
                           <option value="3,600">100 Seder Meals for $3,600</option>
                           <option value="1,800">50 Seder Meals for $1,800</option>
                           <option value="900">25 Seder Meals for $900</option>
                           <option value="720">20 Seder Meals for $720</option>
                           <option value="540">15 Seder Meals for $540</option>
                           <option value="360">10 Seder Meals for $360</option>
                           <option value="180">5 Seder Meals for $180</option>
                           <option value="108">3 Seder Meals for $108</option>
                           <option value="72">2 Seder Meals for $72</option>
                           <option value="36">1 Seder Meal for $36</option>
                         </select>
                         ASE <a href="donation_f.php" class="headerNewsHP">CLICK HERE</a></span></div>                           </TD>
                          </TR>
						    <? }
							else
							{
						   ?>
							  
                              <TR bgcolor="#F3F3F3">
                                <TD WIDTH="50%" CLASS="text1"><DIV ALIGN="right"> &nbsp;
                                        <SELECT ID="payment" NAME="Amount_of_payment" ONCHANGE="js:calcTotal()" CLASS="headerNewsHP">
                                          <OPTION VALUE="" selected>Montant</OPTION>
                                          <OPTION VALUE="10,000">$10,000</OPTION>
                                          <OPTION VALUE="5,000">$5,000</OPTION>
                                          <OPTION VALUE="3,600">$3,600</OPTION>
                                          <OPTION VALUE="1,800">$1,800</OPTION>
                                          <OPTION VALUE="1,000">$1,000</OPTION>
                                          <OPTION VALUE="360">$360</OPTION>
                                          <OPTION VALUE="180">$180</OPTION>
                                          <OPTION VALUE="100">$100</OPTION>
                                          <OPTION VALUE="72">$72</OPTION>
                                          <OPTION VALUE="36">$36</OPTION>
                                          <OPTION VALUE="18">$18</OPTION>
                                        </SELECT>
                                </DIV></TD>
                                <TD WIDTH="50%" CLASS="headerNewsHP">par mois
                                  <INPUT NAME="Number_of_payments" TYPE="text" CLASS="headerNewsHP" ID="months" ONCHANGE="js:calcTotal()" value="1" SIZE="2" MAXLENGTH="3">
                                  mois</TD>
                              </TR><? } ?>
                              <tr bgcolor="#F3F3F3">
                                <td colspan="2" class="text1"><div align="center" class="headerNewsHP">Pour donner, inscrivez le montant</div></td>
                              </tr>
                              <tr bgcolor="#F3F3F3">
                                <td colspan="2" class="textRed"><div align="center"> <img src="images/36_payments_bottom.gif" width="382" height="15">
                                        <?php if ( $_GET['donate'] != "" )
						  {  echo "<br>"."<strong>$".$_GET['Total']."</strong> ". $_GET['donate'];}  ?>
                                </div></td>
                              </tr>
                              <TR bgcolor="#F3F3F3">
                                <TD WIDTH="50%" CLASS="headerNewsHP"><DIV ALIGN="right"> <A NAME="Total"></A><span class="textRed">*</span>Total: 
                                   </DIV></TD>
                                <TD WIDTH="50%" CLASS="headerNewsHP"><B>
                                  <INPUT NAME="Total" TYPE="text" CLASS="headerNewsHP" ID="totalpay" value="<?php echo $_GET['Total'] ?>" SIZE="10" MAXLENGTH="10">
                                  </B> <B>
                                  <INPUT ID="totalpay2" NAME="total2" MAXLENGTH="10" SIZE="10" CLASS="headerNewsHP" TYPE="hidden">
                                  <select name="USAD/EURO/NIS" CLASS="headerNewsHP">
                             <option selected>EUR &euro;</option><option >CAD $</option> <option >$ USD</option><option >NIS</option>
                              
                              <option >GBP &pound;</option>
                              
                              <option >AUD $</option>
                            </select>
                                </B></TD>
                              </TR>
                              <tr bgcolor="#F3F3F3">
                                <td width="50%" class="headerNewsHP"><div align="right"> 
                                  comment avez-vous entendu<br>
                                   parler de nous? 
                                </div></td>
                                <td width="50%" class="headerNewsHP"><b>
                                  <input type="text" name="How_Did_You_Find_Us" maxlength="100" class="headerNewsHP">
                                </b></td>
                              </tr>
                              <tr bgcolor="#F3F3F3">
                                <td width="50%" class="headerNewsHP"><div align="right">Ce don est
 en l'honneur de:</div></td>
                                <td width="50%" class="headerNewsHP">&nbsp;</td>
                              </tr>
                              <tr bgcolor="#F3F3F3">
                                <td width="50%" class="headerNewsHP"><div align="right"> pour réussite, santé,...</div></td>
                                <td width="50%" class="headerNewsHP"><b>
                                  <input type="text" name="In_Honor_of" maxlength="100" class="headerNewsHP">
                                </b></td>
                              </tr>
                              <tr bgcolor="#F3F3F3">
                                <td width="50%" class="headerNewsHP"><div align="right"> en mémoire de:</div></td>
                                <td width="50%" class="headerNewsHP"><b>
                                  <input type="text" name="In_Memory_of" maxlength="100" class="headerNewsHP">
                                </b></td>
                              </tr>
                              <tr bgcolor="#F3F3F3">
                                <td width="50%" class="text1"><div align="right" class="headerNewsHP"> Observations:</div></td>
                                <td width="50%" bgcolor="#F3F3F3" class="text1"><b>
                                  <a name="111" id="111"></a>
                                  <textarea name="Comments"   cols="30" rows="4" class="headerNewsHP"> <?php echo $_GET['Comments'] ?></textarea>
                                </b></td>
                              </tr>
                              
                              <tr>
                                <td width="50%"><div align="right">
                                    <input type="reset" name="clear" value="effacer" class="frame">
                                </div></td>
                                <td width="50%"><input type=submit value="envoyer" class="frame">                                </td>
                              </tr>
                          </table>
                            <span class="headerNewsHP"><b>
                            
                            </b></span></td>
                        </tr>
                      </table>
                    </form>

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AnonSec Team