<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next Session("FP_OldCodePage") = Session.CodePage Session("FP_OldLCID") = Session.LCID Session.CodePage = 1252 Err.Clear strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("docx-connect_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "doc_reg", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(47) Dim arFormDBFields0(47) Dim arFormValues0(47) arFormFields0(0) = "doc_teach1" arFormDBFields0(0) = "doc_teach1" arFormValues0(0) = Request("doc_teach1") arFormFields0(1) = "doc_stay_4wk" arFormDBFields0(1) = "doc_stay_4wk" arFormValues0(1) = Request("doc_stay_4wk") arFormFields0(2) = "fluency_ot" arFormDBFields0(2) = "fluency_ot" arFormValues0(2) = Request("fluency_ot") arFormFields0(3) = "fluency_ch" arFormDBFields0(3) = "fluency_ch" arFormValues0(3) = Request("fluency_ch") arFormFields0(4) = "C2" arFormDBFields0(4) = "C2" arFormValues0(4) = Request("C2") arFormFields0(5) = "doc_l_name" arFormDBFields0(5) = "doc_l_name" arFormValues0(5) = Request("doc_l_name") arFormFields0(6) = "C3" arFormDBFields0(6) = "C3" arFormValues0(6) = Request("C3") arFormFields0(7) = "doc_country" arFormDBFields0(7) = "doc_country" arFormValues0(7) = Request("doc_country") arFormFields0(8) = "doc_end" arFormDBFields0(8) = "doc_end" arFormValues0(8) = Request("doc_end") arFormFields0(9) = "doc_stay_1yr" arFormDBFields0(9) = "doc_stay_1yr" arFormValues0(9) = Request("doc_stay_1yr") arFormFields0(10) = "doc_stay_6wk" arFormDBFields0(10) = "doc_stay_6wk" arFormValues0(10) = Request("doc_stay_6wk") arFormFields0(11) = "doc_country1" arFormDBFields0(11) = "doc_country1" arFormValues0(11) = Request("doc_country1") arFormFields0(12) = "C4" arFormDBFields0(12) = "C4" arFormValues0(12) = Request("C4") arFormFields0(13) = "doc_fax" arFormDBFields0(13) = "doc_fax" arFormValues0(13) = Request("doc_fax") arFormFields0(14) = "doc_country2" arFormDBFields0(14) = "doc_country2" arFormValues0(14) = Request("doc_country2") arFormFields0(15) = "C5" arFormDBFields0(15) = "C5" arFormValues0(15) = Request("C5") arFormFields0(16) = "doc_child" arFormDBFields0(16) = "doc_child" arFormValues0(16) = Request("doc_child") arFormFields0(17) = "doc_stay_8wk" arFormDBFields0(17) = "doc_stay_8wk" arFormValues0(17) = Request("doc_stay_8wk") arFormFields0(18) = "doc_country3" arFormDBFields0(18) = "doc_country3" arFormValues0(18) = Request("doc_country3") arFormFields0(19) = "doc_email" arFormDBFields0(19) = "doc_email" arFormValues0(19) = Request("doc_email") arFormFields0(20) = "doc_lang_other" arFormDBFields0(20) = "doc_lang_other" arFormValues0(20) = Request("doc_lang_other") arFormFields0(21) = "doc_phone_eve" arFormDBFields0(21) = "doc_phone_eve" arFormValues0(21) = Request("doc_phone_eve") arFormFields0(22) = "fluency_fr" arFormDBFields0(22) = "fluency_fr" arFormValues0(22) = Request("fluency_fr") arFormFields0(23) = "doc_f_name" arFormDBFields0(23) = "doc_f_name" arFormValues0(23) = Request("doc_f_name") arFormFields0(24) = "doc_address1" arFormDBFields0(24) = "doc_address1" arFormValues0(24) = Request("doc_address1") arFormFields0(25) = "doc_host" arFormDBFields0(25) = "doc_host" arFormValues0(25) = Request("doc_host") arFormFields0(26) = "doc_dis2" arFormDBFields0(26) = "doc_dis2" arFormValues0(26) = Request("doc_dis2") arFormFields0(27) = "doc_cert2" arFormDBFields0(27) = "doc_cert2" arFormValues0(27) = Request("doc_cert2") arFormFields0(28) = "fluency_sp" arFormDBFields0(28) = "fluency_sp" arFormValues0(28) = Request("fluency_sp") arFormFields0(29) = "doc_profession" arFormDBFields0(29) = "doc_profession" arFormValues0(29) = Request("doc_profession") arFormFields0(30) = "doc_address2" arFormDBFields0(30) = "doc_address2" arFormValues0(30) = Request("doc_address2") arFormFields0(31) = "doc_comments1" arFormDBFields0(31) = "doc_comments1" arFormValues0(31) = Request("doc_comments1") arFormFields0(32) = "doc_start" arFormDBFields0(32) = "doc_start" arFormValues0(32) = Request("doc_start") arFormFields0(33) = "doc_email2" arFormDBFields0(33) = "doc_email2" arFormValues0(33) = Request("doc_email2") arFormFields0(34) = "doc_state" arFormDBFields0(34) = "doc_state" arFormValues0(34) = Request("doc_state") arFormFields0(35) = "doc_adults" arFormDBFields0(35) = "doc_adults" arFormValues0(35) = Request("doc_adults") arFormFields0(36) = "doc_specialty" arFormDBFields0(36) = "doc_specialty" arFormValues0(36) = Request("doc_specialty") arFormFields0(37) = "doc_techniques" arFormDBFields0(37) = "doc_techniques" arFormValues0(37) = Request("doc_techniques") arFormFields0(38) = "fluency_ar" arFormDBFields0(38) = "fluency_ar" arFormValues0(38) = Request("fluency_ar") arFormFields0(39) = "doc_phone_day" arFormDBFields0(39) = "doc_phone_day" arFormValues0(39) = Request("doc_phone_day") arFormFields0(40) = "doc_post_code" arFormDBFields0(40) = "doc_post_code" arFormValues0(40) = Request("doc_post_code") arFormFields0(41) = "doc_city" arFormDBFields0(41) = "doc_city" arFormValues0(41) = Request("doc_city") arFormFields0(42) = "doc_stay_6month" arFormDBFields0(42) = "doc_stay_6month" arFormValues0(42) = Request("doc_stay_6month") arFormFields0(43) = "doc_stay_2wk" arFormDBFields0(43) = "doc_stay_2wk" arFormValues0(43) = Request("doc_stay_2wk") arFormFields0(44) = "doc_stay_4month" arFormDBFields0(44) = "doc_stay_4month" arFormValues0(44) = Request("doc_stay_4month") arFormFields0(45) = "C1" arFormDBFields0(45) = "C1" arFormValues0(45) = Request("C1") arFormFields0(46) = "doc_board" arFormDBFields0(46) = "doc_board" arFormValues0(46) = Request("doc_board") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If FP_SaveFieldToDB fp_rs, Now, "Timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close FP_FormConfirmation "text/html; charset=windows-1252",_ "Form Confirmation",_ "Thank you for submitting the following information:",_ "doc_reg.asp",_ "Return to the form." End If End If Session.CodePage = Session("FP_OldCodePage") Session.LCID = Session("FP_OldLCID") %> Profession
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