BioLume (307) -- BioLume OptIn (135)

member - Biolume Add Members

FormID: 132 AccountID: 135

RESPONSIVE config-member.php file: <?php $arHandlebarView["template"] = "form-whatever"; if ($useThanks!=true) { $arHandlebarView["headerText"] = ''; $arHandlebarView["descriptionText"] = $reqmessage.''; $arHandlebarForm["hiddenSection"][] = array("name"=>"FormID","value"=>"0000000132"); $arHandlebarForm["hiddenSection"][] = array("name"=>"AID","value"=>"0000000135"); $arHandlebarForm["hiddenSection"][] = array("name"=>"ref","value"=>$_REQUEST['ref']); $arHandlebarForm["hiddenSection"][] = array("name"=>"ET","value"=>$_REQUEST['ET']); $arHandlebarForm["hiddenSection"][] = array("name"=>"FT","value"=>$_REQUEST['FT']); if ($_REQUEST['PID']<>"") $_REQUEST['Num']=$_REQUEST['PID']; if ($_REQUEST['Num']<>"") $arHandlebarForm["hiddenSection"][] = array("name"=>"PID","value"=>$_REQUEST['Num']); $arContactSection["FirstName"] = array("type"=>"input","required"=>1,"label"=>" First Name:","name"=>"FirstName","id"=>"FirstName","maxlength"=>24,"value"=>$_REQUEST["FirstName"]); $arContactSection["LastName"] = array("type"=>"input","required"=>0,"label"=>" Last Name:","name"=>"LastName","id"=>"LastName","maxlength"=>32,"value"=>$_REQUEST["LastName"]); $arContactSection["Email"] = array("type"=>"input","required"=>1,"label"=>" Email:","name"=>"Email","id"=>"Email","maxlength"=>64,"value"=>$_REQUEST["Email"]); $arContactSection["Phone"] = array("type"=>"input","required"=>1,"label"=>" Phone:","name"=>"Phone","id"=>"Phone","maxlength"=>16,"value"=>$_REQUEST["Phone"]); $arContactSection["Phone2"] = array("type"=>"input","required"=>0,"label"=>" Phone2:","name"=>"Phone2","id"=>"Phone2","maxlength"=>16,"value"=>$_REQUEST["Phone2"]); $arContactSection["Address1"] = array("type"=>"input","required"=>0,"label"=>" Address1:","name"=>"Address1","id"=>"Address1","maxlength"=>48,"value"=>$_REQUEST["Address1"]); $arContactSection["Address2"] = array("type"=>"input","required"=>0,"label"=>" Address2:","name"=>"Address2","id"=>"Address2","maxlength"=>48,"value"=>$_REQUEST["Address2"]); $arContactSection["City"] = array("type"=>"input","required"=>0,"label"=>" City:","name"=>"City","id"=>"City","maxlength"=>24,"value"=>$_REQUEST["City"]); $arContactSection["State"] = array("type"=>"select","required"=>0,"label"=>" State:","name"=>"State","id"=>"State","data"=>array( array("value"=>"","label"=>"State/Province"),array("value"=>"AL","label"=>"Alabama","selected"=>(($URL_State=="AL")?1:0)),array("value"=>"AK","label"=>"Alaska","selected"=>(($URL_State=="AK")?1:0)),array("value"=>"AZ","label"=>"Arizona","selected"=>(($URL_State=="AZ")?1:0)),array("value"=>"AR","label"=>"Arkansas","selected"=>(($URL_State=="AR")?1:0)),array("value"=>"CA","label"=>"California","selected"=>(($URL_State=="CA")?1:0)),array("value"=>"CO","label"=>"Colorado","selected"=>(($URL_State=="CO")?1:0)),array("value"=>"CT","label"=>"Connecticut","selected"=>(($URL_State=="CT")?1:0)),array("value"=>"DE","label"=>"Delaware","selected"=>(($URL_State=="DE")?1:0)),array("value"=>"DC","label"=>"Dist. of Columbia","selected"=>(($URL_State=="DC")?1:0)),array("value"=>"FL","label"=>"Florida","selected"=>(($URL_State=="FL")?1:0)),array("value"=>"GA","label"=>"Georgia","selected"=>(($URL_State=="GA")?1:0)),array("value"=>"HI","label"=>"Hawaii","selected"=>(($URL_State=="HI")?1:0)),array("value"=>"ID","label"=>"Idaho","selected"=>(($URL_State=="ID")?1:0)),array("value"=>"IL","label"=>"Illinois","selected"=>(($URL_State=="IL")?1:0)),array("value"=>"IN","label"=>"Indiana","selected"=>(($URL_State=="IN")?1:0)),array("value"=>"IA","label"=>"Iowa","selected"=>(($URL_State=="IA")?1:0)),array("value"=>"KS","label"=>"Kansas","selected"=>(($URL_State=="KS")?1:0)),array("value"=>"KY","label"=>"Kentucky","selected"=>(($URL_State=="KY")?1:0)),array("value"=>"LA","label"=>"Louisiana","selected"=>(($URL_State=="LA")?1:0)),array("value"=>"ME","label"=>"Maine","selected"=>(($URL_State=="ME")?1:0)),array("value"=>"MD","label"=>"Maryland","selected"=>(($URL_State=="MD")?1:0)),array("value"=>"MA","label"=>"Massachusetts","selected"=>(($URL_State=="MA")?1:0)),array("value"=>"MI","label"=>"Michigan","selected"=>(($URL_State=="MI")?1:0)),array("value"=>"MN","label"=>"Minnesota","selected"=>(($URL_State=="MN")?1:0)),array("value"=>"MS","label"=>"Mississippi","selected"=>(($URL_State=="MS")?1:0)),array("value"=>"MO","label"=>"Missouri","selected"=>(($URL_State=="MO")?1:0)),array("value"=>"MT","label"=>"Montana","selected"=>(($URL_State=="MT")?1:0)),array("value"=>"NE","label"=>"Nebraska","selected"=>(($URL_State=="NE")?1:0)),array("value"=>"NV","label"=>"Nevada","selected"=>(($URL_State=="NV")?1:0)),array("value"=>"NH","label"=>"New Hampshire","selected"=>(($URL_State=="NH")?1:0)),array("value"=>"NJ","label"=>"New Jersey","selected"=>(($URL_State=="NJ")?1:0)),array("value"=>"NM","label"=>"New Mexico","selected"=>(($URL_State=="NM")?1:0)),array("value"=>"NY","label"=>"New York","selected"=>(($URL_State=="NY")?1:0)),array("value"=>"NC","label"=>"North Carolina","selected"=>(($URL_State=="NC")?1:0)),array("value"=>"ND","label"=>"North Dakota","selected"=>(($URL_State=="ND")?1:0)),array("value"=>"OH","label"=>"Ohio","selected"=>(($URL_State=="OH")?1:0)),array("value"=>"OK","label"=>"Oklahoma","selected"=>(($URL_State=="OK")?1:0)),array("value"=>"OR","label"=>"Oregon","selected"=>(($URL_State=="OR")?1:0)),array("value"=>"PA","label"=>"Pennsylvania","selected"=>(($URL_State=="PA")?1:0)),array("value"=>"RI","label"=>"Rhode Island","selected"=>(($URL_State=="RI")?1:0)),array("value"=>"SC","label"=>"South Carolina","selected"=>(($URL_State=="SC")?1:0)),array("value"=>"SD","label"=>"South Dakota","selected"=>(($URL_State=="SD")?1:0)),array("value"=>"TN","label"=>"Tennessee","selected"=>(($URL_State=="TN")?1:0)),array("value"=>"TX","label"=>"Texas","selected"=>(($URL_State=="TX")?1:0)),array("value"=>"UT","label"=>"Utah","selected"=>(($URL_State=="UT")?1:0)),array("value"=>"VT","label"=>"Vermont","selected"=>(($URL_State=="VT")?1:0)),array("value"=>"VA","label"=>"Virginia","selected"=>(($URL_State=="VA")?1:0)),array("value"=>"WA","label"=>"Washington","selected"=>(($URL_State=="WA")?1:0)),array("value"=>"WV","label"=>"West Virginia","selected"=>(($URL_State=="WV")?1:0)),array("value"=>"WI","label"=>"Wisconsin","selected"=>(($URL_State=="WI")?1:0)),array("value"=>"WY","label"=>"Wyoming","selected"=>(($URL_State=="WY")?1:0)),array("value"=>"GU","label"=>"Guam","selected"=>(($URL_State=="GU")?1:0)),array("value"=>"PR","label"=>"Puerto Rico","selected"=>(($URL_State=="PR")?1:0)),array("value"=>"VI","label"=>"Virgin Island","selected"=>(($URL_State=="VI")?1:0)),array("value"=>"AB","label"=>"Alberta","selected"=>(($URL_State=="AB")?1:0)),array("value"=>"BC","label"=>"British Columbia","selected"=>(($URL_State=="BC")?1:0)),array("value"=>"MB","label"=>"Manitoba","selected"=>(($URL_State=="MB")?1:0)),array("value"=>"NB","label"=>"New Brunswick","selected"=>(($URL_State=="NB")?1:0)),array("value"=>"NF","label"=>"Newfoundland","selected"=>(($URL_State=="NF")?1:0)),array("value"=>"NT","label"=>"NW Territories","selected"=>(($URL_State=="NT")?1:0)),array("value"=>"NS","label"=>"Nova Scotia","selected"=>(($URL_State=="NS")?1:0)),array("value"=>"ON","label"=>"Ontario","selected"=>(($URL_State=="ON")?1:0)),array("value"=>"PE","label"=>"Prince Edward Isl","selected"=>(($URL_State=="PE")?1:0)),array("value"=>"QB","label"=>"Quebec","selected"=>(($URL_State=="QB")?1:0)),array("value"=>"SK","label"=>"Saskatchewan","selected"=>(($URL_State=="SK")?1:0)),array("value"=>"YT","label"=>"Yukon Territory","selected"=>(($URL_State=="YT")?1:0)) ) ); $arContactSection["Zip"] = array("type"=>"input","required"=>0,"label"=>" Zip:","name"=>"Zip","id"=>"Zip","maxlength"=>10,"value"=>$_REQUEST["Zip"]); $arContactSection["Country"] = array("type"=>"select","required"=>0,"label"=>" Country:","name"=>"Country","id"=>"Country","data"=>array( array("value"=>"","label"=>"Country"),array("value"=>"United States of America","label"=>"United States of America","selected"=>(($URL_Country=="United States of America")?1:0)),array("value"=>"Canada","label"=>"Canada","selected"=>(($URL_Country=="Canada")?1:0)),array("value"=>"United Kingdom","label"=>"United Kingdom","selected"=>(($URL_Country=="United Kingdom")?1:0)),array("value"=>"Afghanistan","label"=>"Afghanistan","selected"=>(($URL_Country=="Afghanistan")?1:0)),array("value"=>"Aland Islands","label"=>"Aland Islands","selected"=>(($URL_Country=="Aland Islands")?1:0)),array("value"=>"Albania","label"=>"Albania","selected"=>(($URL_Country=="Albania")?1:0)),array("value"=>"Algeria","label"=>"Algeria","selected"=>(($URL_Country=="Algeria")?1:0)),array("value"=>"American Samoa","label"=>"American Samoa","selected"=>(($URL_Country=="American Samoa")?1:0)),array("value"=>"Andorra","label"=>"Andorra","selected"=>(($URL_Country=="Andorra")?1:0)),array("value"=>"Angola","label"=>"Angola","selected"=>(($URL_Country=="Angola")?1:0)),array("value"=>"Anguilla","label"=>"Anguilla","selected"=>(($URL_Country=="Anguilla")?1:0)),array("value"=>"Antigua and Barbuda","label"=>"Antigua and Barbuda","selected"=>(($URL_Country=="Antigua and Barbuda")?1:0)),array("value"=>"Argentina","label"=>"Argentina","selected"=>(($URL_Country=="Argentina")?1:0)),array("value"=>"Armenia","label"=>"Armenia","selected"=>(($URL_Country=="Armenia")?1:0)),array("value"=>"Aruba","label"=>"Aruba","selected"=>(($URL_Country=="Aruba")?1:0)),array("value"=>"Australia","label"=>"Australia","selected"=>(($URL_Country=="Australia")?1:0)),array("value"=>"Austria","label"=>"Austria","selected"=>(($URL_Country=="Austria")?1:0)),array("value"=>"Azerbaijan","label"=>"Azerbaijan","selected"=>(($URL_Country=="Azerbaijan")?1:0)),array("value"=>"Bahamas","label"=>"Bahamas","selected"=>(($URL_Country=="Bahamas")?1:0)),array("value"=>"Bahrain","label"=>"Bahrain","selected"=>(($URL_Country=="Bahrain")?1:0)),array("value"=>"Bangladesh","label"=>"Bangladesh","selected"=>(($URL_Country=="Bangladesh")?1:0)),array("value"=>"Barbados","label"=>"Barbados","selected"=>(($URL_Country=="Barbados")?1:0)),array("value"=>"Belarus","label"=>"Belarus","selected"=>(($URL_Country=="Belarus")?1:0)),array("value"=>"Belgium","label"=>"Belgium","selected"=>(($URL_Country=="Belgium")?1:0)),array("value"=>"Belize","label"=>"Belize","selected"=>(($URL_Country=="Belize")?1:0)),array("value"=>"Benin","label"=>"Benin","selected"=>(($URL_Country=="Benin")?1:0)),array("value"=>"Bermuda","label"=>"Bermuda","selected"=>(($URL_Country=="Bermuda")?1:0)),array("value"=>"Bhutan","label"=>"Bhutan","selected"=>(($URL_Country=="Bhutan")?1:0)),array("value"=>"Bolivia","label"=>"Bolivia","selected"=>(($URL_Country=="Bolivia")?1:0)),array("value"=>"Bosnia and Herzegovina","label"=>"Bosnia and Herzegovina","selected"=>(($URL_Country=="Bosnia and Herzegovina")?1:0)),array("value"=>"Botswana","label"=>"Botswana","selected"=>(($URL_Country=="Botswana")?1:0)),array("value"=>"Brazil","label"=>"Brazil","selected"=>(($URL_Country=="Brazil")?1:0)),array("value"=>"British Virgin Islands","label"=>"British Virgin Islands","selected"=>(($URL_Country=="British Virgin Islands")?1:0)),array("value"=>"Brunei Darussalam","label"=>"Brunei Darussalam","selected"=>(($URL_Country=="Brunei Darussalam")?1:0)),array("value"=>"Bulgaria","label"=>"Bulgaria","selected"=>(($URL_Country=="Bulgaria")?1:0)),array("value"=>"Burkina Faso","label"=>"Burkina Faso","selected"=>(($URL_Country=="Burkina 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Ivoire")?1:0)),array("value"=>"Croatia","label"=>"Croatia","selected"=>(($URL_Country=="Croatia")?1:0)),array("value"=>"Cuba","label"=>"Cuba","selected"=>(($URL_Country=="Cuba")?1:0)),array("value"=>"Cyprus","label"=>"Cyprus","selected"=>(($URL_Country=="Cyprus")?1:0)),array("value"=>"Czech Republic","label"=>"Czech Republic","selected"=>(($URL_Country=="Czech Republic")?1:0)),array("value"=>"Denmark","label"=>"Denmark","selected"=>(($URL_Country=="Denmark")?1:0)),array("value"=>"Djibouti","label"=>"Djibouti","selected"=>(($URL_Country=="Djibouti")?1:0)),array("value"=>"Dominica","label"=>"Dominica","selected"=>(($URL_Country=="Dominica")?1:0)),array("value"=>"Dominican Republic","label"=>"Dominican Republic","selected"=>(($URL_Country=="Dominican Republic")?1:0)),array("value"=>"Ecuador","label"=>"Ecuador","selected"=>(($URL_Country=="Ecuador")?1:0)),array("value"=>"Egypt","label"=>"Egypt","selected"=>(($URL_Country=="Egypt")?1:0)),array("value"=>"El Salvador","label"=>"El 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