<?
$emailadres = "...@...nl"; // zet hier jou eigen mail adres neer
?>
<form name="form1" method="post" action="
<? echo $PHP_SELF; ?>">
<table width="92%" border="0">
<tr>
<td colspan="3"><span class="style14">Persoonlijke gegevens </span></td>
</tr>
<tr>
<td><span class="style15">Voornaam:</span></td>
<td colspan="2"><input name="voornaam" type="text" id="voornaam" value="" /></td>
</tr>
<tr>
<td><span class="style15">Tussenvoegsel:</span></td>
<td colspan="2"><input name="tussenvoegsel" type="text" id="tussenvoegsel" value="" /></td>
</tr>
<tr>
<td><span class="style15">Achternaam:</span></td>
<td colspan="2"><input name="achternaam" type="text" id="achternaam" value="" /></td>
</tr>
<tr>
<td><span class="style15">Adres:</span></td>
<td colspan="2"><input name="adres" type="text" id="adres" value="" /></td>
</tr>
<tr>
<td><span class="style15">Postcode & woonplaats: </span></td>
<td colspan="2"><input name="postcode" type="text" id="postcode" value="" size="10" maxlength="7" />
<input name="woonplaats" type="text" id="woonplaats" value="" /></td>
</tr>
<tr>
<td><span class="style15">Telefoonnummer:</span></td>
<td colspan="2"><input name="telefoon" type="text" id="telefoon" value="" /></td>
</tr>
<tr>
<td><span class="style15">Mobielnummer:</span></td>
<td colspan="2"><input name="mobielnummer" type="text" id="mobielnummer" value="" /></td>
</tr>
<tr>
<td height="21"><span class="style15">E-mailadres:</span></td>
<td height="21" colspan="2"><input name="email" type="text" id="email" value="" /></td>
</tr>
<tr>
<td height="35" colspan="3"> </td>
</tr>
<tr>
<td colspan="3"><span class="style15"><strong>Feest gegevens </strong></span></td>
</tr>
<tr>
<td><span class="style15">Datum van feest:</span></td>
<td colspan="2"><select name="dag" id="dag">
<option selected="selected">dag</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
-
<select name="maand" id="maand">
<option selected="selected">maand</option>
<option value="01">Januari</option>
<option value="02">Februari</option>
<option value="03">Maart</option>
<option value="04">April</option>
<option value="05">Mei</option>
<option value="06">Juni</option>
<option value="07">Juli</option>
<option value="08">Augustus</option>
<option value="09">September</option>
<option value="10">Oktober</option>
<option value="11">November</option>
<option value="12">December</option>
</select>
-
<select name="jaar" id="jaar">
<option selected="selected">jaar</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
</select></td>
</tr>
<tr>
<td><span class="style15">Aanvang en eindtijd van feest:</span></td>
<td colspan="2"><span class="style15">Van
<input name="aanvang" type="text" id="aanvang" value="" size="5" maxlength="5" />
uur tot
uur
<input name="eindtijd" type="text" id="eindtijd" value="" size="5" maxlength="5" />
</span></td>
</tr>
<tr>
<td><span class="style15">Naam van locatie:</span></td>
<td colspan="2"><input name="naam-locatie" type="text" id="naam-locatie" value="" />
<span class="style15"> </span></td>
</tr>
<tr>
<td><span class="style15">Adres van locatie: </span></td>
<td colspan="2"><input name="locatie-plaats" type="text" id="locatie-plaats" value="" /></td>
</tr>
<tr>
<td><span class="style15">Postcode & plaats:</span></td>
<td colspan="2"><input name="postcode" type="text" id="postcode" value="" />
<input name="plaats" type="text" id="plaats" value="" size="10" maxlength="7" /> </td>
</tr>
<tr>
<td><span class="style15">Soort feest: </span></td>
<td colspan="2"><input name="soortfeest" type="text" id="soortfeest" value="" /></td>
</tr>
<tr>
<td><span class="style15">Evt. Thema van het feest: </span></td>
<td colspan="2"><input name="thema" type="text" id="thema" value="" /></td>
</tr>
<tr>
<td><span class="style15">Vind het feest binnen of buiten plaats:</span></td>
<td colspan="2"><select name="binnenbuiten" id="binnenbuiten">
<option value="Binnen" selected="selected">Binnen</option>
<option value="Buiten">Buiten</option>
</select></td>
</tr>
<tr>
<td><span class="style15">Wat is het verwachte aantal bezoekers: </span></td>
<td colspan="2"><input name="bezoekers" type="text" id="bezoekers" size="8" maxlength="4" value="" />
<span class="style15">bezoekers</span></td>
</tr>
<tr>
<td><span class="style15">Wat is de gemiddelde leeftijd van de bezoekers: </span></td>
<td colspan="2"><input name="leeftijd" type="text" id="leeftijd" value="" size="8" maxlength="4" />
<span class="style15">jaar </span></td>
</tr>
<tr>
<td><span class="style15">Mag er een rookmachine worden gebruikt: </span></td>
<td colspan="2"><select name="rookmachine" id="rookmachine">
<option value="Ja" selected="selected">Ja</option>
<option value="Nee">Nee</option>
</select></td>
</tr>
<tr>
<td><span class="style15">Mogen er foto's worden gemaakt, en mogen deze op het internet worden geplaatst? (De fotopagina van DJ-XL.nl) </span></td>
<td colspan="2"><select name="fotos" id="fotos">
<option value="Ja" selected="selected">Ja</option>
<option value="Nee">Nee</option>
</select></td>
</tr>
<tr>
<td><span class="style15">Is het feest op een etage?</span></td>
<td colspan="2"><select name="etage" id="select">
<option value="Ja">Ja</option>
<option value="Nee" selected="selected">Nee</option>
</select></td>
</tr>
<tr>
<td height="21"><span class="style15">Zoja, is er een (bruikbare) lift aanwezig?</span></td>
<td height="21" colspan="2"><select name="lift" id="select2">
<option selected="selected">----</option>
<option value="Ja">Ja</option>
<option value="Nee">Nee</option>
</select></td>
</tr>
<tr>
<td height="42" colspan="3"> </td>
</tr>
<tr>
<td colspan="3"><span class="style14">Tijd & prijs </span></td>
</tr>
<tr>
<td><span class="style15">1 uur </span></td>
<td width="6%"><span class="style15">10</span></td>
<td width="32%"><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">2 uur </span></td>
<td><span class="style15">20</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">3 uur </span></td>
<td><span class="style15">30</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">4 uur </span></td>
<td><span class="style15">40</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">5 uur </span></td>
<td><span class="style15">50</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">6 uur </span></td>
<td><span class="style15">60</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">7 uur </span></td>
<td><span class="style15">70</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">8 uur </span></td>
<td><span class="style15">80</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">9 uur </span></td>
<td><span class="style15">90</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td><span class="style15">10 uur </span></td>
<td><span class="style15">100</span></td>
<td><input type="checkbox" name="checkbox" value="checkbox"></td>
</tr>
<tr>
<td colspan="3"><span class="style14">Extra informatie </span></td>
</tr>
<tr>
<td colspan="3"> </td>
</tr>
<tr>
<td colspan="3"><span class="style15">Opmerking:</span></td>
</tr>
<tr>
<td colspan="3"><span class="style15">Algemene voorwaarden:</span></td>
</tr>
<tr align="center" valign="middle">
<td height="139" colspan="3"><div align="center" class="style16">
Klik hier voor de voorwaarden </div></td>
</tr>
<tr>
<td width="62%"><span class="style15">Gaat u akkoord met de algemene voorwaarden? </span></td>
<td colspan="2"><span class="style15">ja
<input type="checkbox" name="checkbox" value="checkbox">
nee
<input type="checkbox" name="checkbox" value="checkbox">
</span></td>
</tr>
<tr>
<td colspan="3"><input name="verzend-boekingen" type="submit" id="verzend-boekingen" value="verzenden"></td>
</tr>
</table>
</form>
<?
zou iemand dit voor mij willen bewerken
}
else
{
// maak hier je eigen error van
echo"Sorry error, het boekformulier van DJ MC Sander mati D is niet correct ingevuld, wil u duidelijk nog een maal het formulier controleren.";
}
}
?>