Please enter your last name."; } if ($_POST['street1'] == "") { $errormessage .= "
Please enter your address."; } if ($_POST['city'] == "") { $errormessage .= "
Please enter your city."; } if ($_POST['zip'] == "") { $errormessage .= "
Please enter your zip code."; } if ($_POST['email'] == "") { $errormessage .= "
Please enter your email address."; } if ($_POST['password'] == "") { $errormessage .= "
Please enter a password."; } if ($_POST['phone'] == "" || $_POST['phone'] == "1234567890 'only numbers'") { $errormessage .= "
Please enter your phone."; } if ($_POST['licensure_type'] == "") { $errormessage .= "
Please enter your license designation."; } if ($_POST['lic_number'] == "") { $errormessage .= "
Please enter your license number."; } if ($errormessage == "") { $sql = "INSERT INTO ceu_online (password, Title, First, MI, Last, Street1, Street2, City, State, Zip, Phone, Email, LicenseNo) VALUES ('".md5($_POST['password'])."', '" . $_POST['title'] . "','" . $_POST['fname'] . "','" . $_POST['mi'] . "','" . $_POST['lname'] . "','" . $_POST['street1'] . "','" . $_POST['street2'] . "','" . $_POST['city'] . "','" . $_POST['state'] . "','" . $_POST['zip'] . "','" . $_POST['phone'] . "','" . $_POST['email'] . "','" . $_POST['licensure_type'] . $_POST['lic_number'] . "')"; mysql_query($sql, $db); $id = mysql_insert_id($db); $message = ""; foreach($_POST as $key=>$value) { $message .= $key.": ".$value."\n"; } $mail_from = $_POST['Email']; $success = mail("ism@marden-ed.com", "CEU Registration", $message,"MIME-Version: 1.0\nContent-type: text/text; charset=iso-8859-1\nFrom: ".$mail_from."\nReply-To: ".$mail_from."\nX-Mailer: PHP/\nMessage-ID: <".md5(uniqid(time()))."@{$_SERVER['SERVER_NAME']}>\n","-f".$mail_from); header("Location: http://www.marden-ed.com/On_line/Test-3.html"); } } ?> Marden Educational Services, LLC – Services

1-800-567-7837

Email Carol:
clm@marden-ed.com

Email Ivan:
ism@marden-ed.com

 

Online CEU Test Registration

*Name

*Address 1

  Address 2

*City *State 

*Zip -

*Phone

*Email

*Password

 Required for Florida Nurses only

*License Designation *License Number