php form and processor:

PHP Code:
<?php
// Receiving variables
@$pfw_ip= $_SERVER['REMOTE_ADDR'];
@$radiobutton = addslashes($_POST['radiobutton']);
@$company_name = addslashes($_POST['company_name']);
@$slogan = addslashes($_POST['slogan']);
@$name = addslashes($_POST['name']);
@$title = addslashes($_POST['title']);
@$address_1 = addslashes($_POST['address_1']);
@$address_2 = addslashes($_POST['address_2']);
@$address_3 = addslashes($_POST['address_3']);
@$phone = addslashes($_POST['phone']);
@$cell = addslashes($_POST['cell']);
@$fax = addslashes($_POST['fax']);
@$vis_email = addslashes($_POST['vis_email']);
@$website = addslashes($_POST['website']);
@$add_info = addslashes($_POST['add_info']);
@$approval = addslashes($_POST['approval']);
 
//Sending Email to form owner
$pfw_header = "From: $vis_email\n"
  . "Reply-To: $vis_email\n";
$pfw_subject = "designer";
$pfw_email_to = "support@rlhanson-online.com";
$pfw_message = "Visitor's IP: $pfw_ip\n"
. "radiobutton: $radiobutton\n"
. "company_name: $company_name\n"
. "slogan: $slogan\n"
. "name: $name\n"
. "title: $title\n"
. "address_1: $address_1\n"
. "address_2: $address_2\n"
. "address_3: $address_3\n"
. "phone: $phone\n"
. "cell: $cell\n"
. "fax: $fax\n"
. "vis_email: $vis_email\n"
. "website: $website\n"
. "add_info: $add_info\n"
. "approval: $approval\n"
. "RL Hanson-Online";
@mail($pfw_email_to, $pfw_subject ,$pfw_message ,$pfw_header ) ;
echo "Design Preview";
echo "<table width='350' height='200' border='0' align='center' cellpadding='0' cellspacing='10' background='<background selection>'>";
echo "<tr>";
echo "<td rowspan='2'>$company_name </td>";
echo "<td><div align='right'>$name </div></td>";
echo "</tr>";
echo "<tr>";
echo "<td><div align='right'>$title</div></td>";
echo "</tr>";
echo "<tr>";
echo "<td colspan='2' align='center'>$slogan</td>";
echo "</tr>";
echo "";
echo "<tr>";
echo "<td>$address_1</td>";
echo "<td align='right'>$phone</td>";
echo "</tr>";
echo "<tr>";
echo "<td>$address_2</td>";
echo "<td align='right'>$cell</td>";
echo "</tr>";
echo "<tr>";
echo "<td>$address_3</td>";
echo "<td align='right'>$fax</td>";
echo "</tr>";
echo "<tr>";
echo "<td>$website</td>";
echo "<td align='right'>$vis_email </td>";
echo "</tr>";
echo "<tr>";
echo "<td colspan='2' align='center'>$add_info</td>";
echo "</tr>";
echo "";
echo "</table>";
 
$thisfile = $_SERVER['PHP_SELF'];
$message .= <<< EOMSG
<form action="$thisfile" method="POST"><input name="recipient" type="hidden" value="support@rlhanson-online.com"><table width="100%" border="0" cellspacing="10" cellpadding="0">
  <tr>
    <td>Customer Input Section - all info is optional </td>
    <td width="50%">&nbsp; </td>
  </tr>
  <tr>
    <td width="50%"><table width="202%" border="0" cellspacing="10" cellpadding="0">
  <tr>
    <td>Background Selection </td>
    <td><label>
      <input name="radiobutton" type="radio" value="radiobutton" tabindex="1"/>
      Blue Image 
      <input name="radiobutton" type="radio" value="radiobutton" tabindex="2" />
      Red Image<br />
      <input name="radiobutton" type="radio" value="radiobutton" tabindex="3" />
      Purple Image 
      <input name="radiobutton" type="radio" value="radiobutton" tabindex="4" />
      No Image</label></td>
  </tr>
  <tr>
    <td>Company Name </td>
    <td><input name="company_name" type="text" id="company_name" tabindex="5" size="25" maxlength="50" /></td>
  </tr>
  <tr>
    <td>Slogan</td>
    <td><input name="slogan" type="text" id="slogan" tabindex="6" size="25" maxlength="100" /></td>
  </tr>
  <tr>
    <td>Full Name </td>
    <td><input name="name" type="text" id="name" tabindex="7" size="25" maxlength="50" /></td>
  </tr>
  <tr>
    <td>Job Title </td>
    <td><input name="title" type="text" id="title" tabindex="8" size="25" maxlength="25" /></td>
  </tr>
  <tr>
    <td>Address - Line 1 </td>
    <td><input name="address_1" type="text" id="address_1" tabindex="9" size="25" maxlength="100" /></td>
  </tr>
  <tr>
    <td>Address - Line 2 </td>
    <td><input name="address_2" type="text" id="address_2" tabindex="10" size="25" maxlength="100" /></td>
  </tr>
  <tr>
    <td>Address - Line 3 </td>
    <td><input name="address_3" type="text" id="address_3" tabindex="11" size="25" maxlength="100" /></td>
  </tr>
  <tr>
    <td>Telephone</td>
    <td><input name="phone" type="text" id="phone" tabindex="12" size="25" maxlength="15" /></td>
  </tr>
  <tr>
    <td>Cell </td>
    <td><input name="cell" type="text" id="cell" tabindex="13" size="25" maxlength="15" /></td>
  </tr>
  <tr>
    <td>Fax</td>
    <td><input name="fax" type="text" id="fax" tabindex="14" size="25" maxlength="15" /></td>
  </tr>
  <tr>
    <td>e-mail Address </td>
    <td><input name="vis_email" type="text" id="vis_email" tabindex="15" size="25" maxlength="50" /></td>
  </tr>
  <tr>
    <td>Website Address </td>
    <td><input name="website" type="text" id="website" tabindex="16" size="25" maxlength="100" /></td>
  </tr>
  <tr>
    <td>Additional Info </td>
    <td><input name="add_info" type="text" id="add_info" tabindex="17" size="25" maxlength="100" /></td>
  </tr>
  <tr>
    <td><label></label></td>
    <td>&nbsp;</td>
  </tr>
</table>    </td>
    <td width="50%" align="center" valign="top">
    <br />
    <label>
    <input name="approval" type="checkbox" id="approval" value="approve" />
    </label>
I approve Design! (required)<br />
<br />
<input type="submit" name="Submit" value="Submit Design!" /></td>
  </tr>
</table> 
</form>
EOMSG;
?>
<html>
<head>
<title>Untitled Document</title>
</head>
<body>
<?php echo $message; ?>
</body>
</html>