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cvieth/content

Created February 13, 2013 12:44
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content
<?php
include_once 'lib/httpHeader.php';
// HTTP Header ausgeben
header(httpHeader::STATUS_200);
header(httpHeader::ENCODING_UTF8);
header(httpHeader::CONTENT_TYPE_HTML);
function echoValue($name) {
global $tplData;
if (isset($tplData['values'][$name]))
echo htmlspecialchars($tplData['values'][$name], ENT_QUOTES, 'UTF-8');
}
?>
<!DOCTYPE html>
<html>
<head>
<?php include("tpl/htmlHeader.php"); ?>
<script type="text/javascript" src="js/DEde_strings.js"></script>
<?php
// Fehler der Backend Validierung ausgeben
if (isset($tplData['errors'])) {
echo '<script type="text/javascript"> var formErrors; formErrors = jQuery.parseJSON(\'' . $tplData['errors'] . '\');</script>';
}
?>
<script type="text/javascript" src="js/regFormValidation.js"></script>
</head>
<body class="notation">
<div id="wrapper">
<div id="content">
<div id="logos"><img src="img/logos_3.png" /></div>
<div id="headline">Probieren Sie jetzt Actimel<sup>®</sup> oder<br/>
ACTIVIA<sup>®</sup> Creme-Genuss und Sie erhalten den Kaufpreis zurückerstattet.
</div>
<div id="howto"><img src="img/soeinfachgehts_img_7.png" /></div>
<form id="tnf_form" method="post">
<div id="intro">
Um an dieser Aktion teilzunehmen, benötigen wir bitte untenstehende Informationen von Ihnen.<br/>
Mit einem (*) markierte Felder müssen ausgefüllt werden.
</div>
<div class="form_headline">
Ihr Einkauf
</div>
<fieldset id="buyout">
<label for="code">Code (*)</label><input type="text" name="code" id="code" value="<?PHP echoValue('code'); ?>"/>
<p id="error_code" class="error"></p>
<label for="price">Einkaufspreis (*)</label><input type="text" name="price" id="price" class="pricein" value="<?PHP echoValue('price'); ?>"/><span>,</span><input type="text" name="price2" id="price2" class="pricein" value="<?PHP echoValue('price2'); ?>"/><span id="euro">€</span>
<p id="error_price" class="error"></p>
<label for="shop">Einkaufsstätte (*)</label>
<select id="shop" name="shop">
<option value="0">bitte auswählen...</option>
<option value="1"<?PHP if ($tplData['values']['shop'] == '1') echo " selected"; ?>>EDEKA</option>
<option value="2"<?PHP if ($tplData['values']['shop'] == '2') echo " selected"; ?>>Globus</option>
<option value="3"<?PHP if ($tplData['values']['shop'] == '3') echo " selected"; ?>>Kaufland</option>
<option value="4"<?PHP if ($tplData['values']['shop'] == '4') echo " selected"; ?>>LIDL</option>
<option value="5"<?PHP if ($tplData['values']['shop'] == '5') echo " selected"; ?>>NETTO</option>
<option value="6"<?PHP if ($tplData['values']['shop'] == '6') echo " selected"; ?>>real,-</option>
<option value="7"<?PHP if ($tplData['values']['shop'] == '7') echo " selected"; ?>>REWE</option>
<option value="8"<?PHP if ($tplData['values']['shop'] == '8') echo " selected"; ?>>Andere</option>
</select>
<p id="error_shop" class="error"></p>
</fieldset>
<hr />
<div class="form_headline">
Ihre Daten
</div>
<fieldset id="personal">
<label for="gender" class="radioGroupLabel">Anrede (*)</label>
<input type="radio" name="gender" id="female" value="female"<?PHP if ($tplData['values']['gender'] == 'female') echo " checked"; ?>/><label for="female" class="gender_label">Frau</label>
<input type="radio" name="gender" id="male" value="male"<?PHP if ($tplData['values']['gender'] == 'male') echo " checked"; ?>/><label class="gender_label" for="male">Herr</label>
<p id="error_gender" class="error"></p>
<label for="surname">Vorname (*)</label><input type="text" name="surname" id="surname" value="<?PHP echoValue('surname'); ?>"/>
<p id="error_surname" class="error"></p>
<label for="lastname">Nachname (*)</label><input type="text" name="lastname" id="lastname" value="<?PHP echoValue('lastname'); ?>"/>
<p id="error_lastname" class="error"></p>
<label for="dob">Geburtstag (*)</label>
<select id="dobDay" name="dobDay">
<option value="0">TT</option>
<?php
for ($i = 1; $i <= 31; $i++) {
if ($i == $tplData['values']['dobDay']) {
if ($i < 10) {
$temp = "0" . $i;
} else {
$temp = $i;
}
echo '<option selected value="' . $i . '">' . $temp . '</option>' . "\n";
} else {
if ($i < 10) {
$temp = "0" . $i;
} else {
$temp = $i;
}
echo '<option value="' . $i . '">' . $temp . '</option>' . "\n";
}
}
unset($i);
?>
</select>
<select id="dobMonth" name="dobMonth">
<option value="0">MM</option>
<?php
$monate = array(1 => "Januar",
2 => "Februar",
3 => "März",
4 => "April",
5 => "Mai",
6 => "Juni",
7 => "Juli",
8 => "August",
9 => "September",
10 => "Oktober",
11 => "November",
12 => "Dezember");
for ($i = 1; $i <= 12; $i++) {
if ($i == $tplData['values']['dobMonth']) {
if ($i < 10) {
$temp = "0" . $i;
} else {
$temp = $i;
}
echo '<option selected value="' . $i . '">' . $temp . '</option>' . "\n";
} else {
if ($i < 10) {
$temp = "0" . $i;
} else {
$temp = $i;
}
echo '<option value="' . $i . '">' . $temp . '</option>' . "\n";
}
}
unset($i);
?>
</select>
<select id="dobYear" name="dobYear">
<option value="0">JJJJ</option>
<?php
for ($i = 1995; $i >= 1920; $i--) {
if ($i == $tplData['values']['dobYear']) {
echo '<option selected value="' . $i . '">' . $i . '</option>' . "\n";
} else {
echo '<option value="' . $i . '">' . $i . '</option>' . "\n";
}
}
unset($i);
?>
</select>
<p id="error_dob" class="error"></p>
<label for="email">E-Mail-Adresse (*)</label><input type="text" name="email" id="email" value="<?PHP echoValue('email'); ?>"/>
<p id="error_email" class="error"></p>
<label for="street">Straße und Hausnummer (*)</label><input type="text" name="street" id="street" value="<?PHP echoValue('street'); ?>"/><input type="text" name="housenumber" id="housenumber" value="<?PHP echoValue('housenumber'); ?>"/>
<p id="error_street" class="error"></p>
<label for="postal_code">Postleitzahl und Ort (*)</label><input type="text" name="postal_code" id="postal_code" value="<?PHP echoValue('postal_code'); ?>"/><input type="text" name="city" id="city" value="<?PHP echoValue('city'); ?>"/>
<p id="error_postal_code" class="error"></p>
</fieldset>
<hr />
<div class="form_headline">
Ihre Bankverbindung
</div>
<fieldset id="pay">
<label for="depositor">Kontoinhaber (*)</label><input type="text" name="depositor" id="depositor" value="<?PHP echoValue('depositor'); ?>"/>
<p id="error_depositor" class="error"></p>
<label for="account">Kontonummer (*)</label><input type="text" name="account" id="account" value="<?PHP echoValue('account'); ?>"/>
<p id="error_account" class="error"></p>
<label for="bankcode">Bankleitzahl (*)</label><input type="text" name="bankcode" id="bankcode" value="<?PHP echoValue('bankcode'); ?>"/>
<p id="error_bankcode" class="error"></p>
<label for="bank">Kreditinstitut (*)</label><input type="text" name="bank" id="bank" value="<?PHP echoValue('bank'); ?>"/>
<p id="error_bank" class="error"></p>
</fieldset>
<hr />
<fieldset id="mafo">
<label for="mafo1">1. Wie viele Kinder leben in Ihrem Haushalt?</label>
<select id="mafo1" name="mafo1">
<option>bitte auswählen...</option>
<option value="0"<?PHP if ($tplData['values']['mafo1'] == '0') echo " selected"; ?>>0</option>
<option value="1"<?PHP if ($tplData['values']['mafo1'] == '1') echo " selected"; ?>>1</option>
<option value="2"<?PHP if ($tplData['values']['mafo1'] == '2') echo " selected"; ?>>2</option>
<option value="3"<?PHP if ($tplData['values']['mafo1'] == '3') echo " selected"; ?>>3 und mehr Kinder</option>
</select>
<label for="mafo2">2. Wie oft kaufen Sie Milchprodukte wie Joghurt, Quark, Pudding etc. ein?</label>
<select id="mafo2" name="mafo2">
<option>bitte auswählen...</option>
<option value="0"<?PHP if ($tplData['values']['mafo2'] == '0') echo " selected"; ?>>mehrmals pro Woche</option>
<option value="1"<?PHP if ($tplData['values']['mafo2'] == '1') echo " selected"; ?>>ca. einmal pro Woche</option>
<option value="2"<?PHP if ($tplData['values']['mafo2'] == '2') echo " selected"; ?>>ein- oder zweimal im Monat</option>
<option value="3"<?PHP if ($tplData['values']['mafo2'] == '3') echo " selected"; ?>>einmal alle 2 oder 3 Monate</option>
<option value="4"<?PHP if ($tplData['values']['mafo2'] == '4') echo " selected"; ?>>seltener</option>
<option value="5"<?PHP if ($tplData['values']['mafo2'] == '5') echo " selected"; ?>>nie</option>
</select>
</fieldset>
<fieldset id="mafo3">
<?PHP if (!(isset($tplData['values']['mafo3']))) $tplData['values']['mafo3'] = array(); ?>
<label for="mafo3" class="groupLabel">3. In welchen Einkaufsstätten kaufen Sie regelmäßig Milchprodukte wie Joghurt, Quark, Pudding etc. ein? (Mehrfachnennung möglich)</label>
<input type="checkbox" class="quest4_answer quest4_answer1" id="quest4_answer1" name="mafo3[]" value="1"<?PHP if (in_array('1', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer1" class="quest4_answer1">EDEKA</label>
<input type="checkbox" class="quest4_answer quest4_answer2" id="quest4_answer2" name="mafo3[]" value="2"<?PHP if (in_array('2', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer2" class="quest4_answer2">REWE</label>
<input type="checkbox" class="quest4_answer quest4_answer3" id="quest4_answer3" name="mafo3[]" value="3"<?PHP if (in_array('3', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer3" class="quest4_answer3">LIDL</label>
<input type="checkbox" class="quest4_answer quest4_answer4" id="quest4_answer4" name="mafo3[]" value="4<?PHP if (in_array('4', $tplData['values']['mafo3'])) echo " checked"; ?>"/><label for="quest4_answer4" class="quest4_answer4">ALDI</label>
<input type="checkbox" class="quest4_answer quest4_answer5 first" id="quest4_answer5" name="mafo3[]" value="5"<?PHP if (in_array('5', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer5" class="quest4_answer5">Kaufland</label>
<input type="checkbox" class="quest4_answer quest4_answer6" id="quest4_answer6" name="mafo3[]" value="6"<?PHP if (in_array('6', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer6" class="quest4_answer6">Globus</label>
<input type="checkbox" class="quest4_answer quest4_answer7" id="quest4_answer7" name="mafo3[]" value="7"<?PHP if (in_array('7', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer7" class="quest4_answer7">Kaiser's/Tengelmann</label>
<input type="checkbox" class="quest4_answer quest4_answer8" id="quest4_answer8" name="mafo3[]" value="8"<?PHP if (in_array('8', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer8" class="quest4_answer8">real,-</label>
<input type="checkbox" class="quest4_answer quest4_answer9 first" id="quest4_answer9" name="mafo3[]" value="9"<?PHP if (in_array('8', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer9" class="quest4_answer9">Penny</label>
<input type="checkbox" class="quest4_answer quest4_answer10" id="quest4_answer10" name="mafo3[]" value="10"<?PHP if (in_array('10', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer10" class="quest4_answer10">Netto</label>
<input type="checkbox" class="quest4_answer quest4_answer11" id="quest4_answer11" name="mafo3[]" value="11"<?PHP if (in_array('11', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer11" class="quest4_answer11">Hit</label>
<input type="checkbox" class="quest4_answer quest4_answer12" id="quest4_answer12" name="mafo3[]" value="12"<?PHP if (in_array('12', $tplData['values']['mafo3'])) echo " checked"; ?>/><label for="quest4_answer12" class="quest4_answer11">Andere</label>
</fieldset>
<hr />
<?PHP $capChallenge = md5(microtime() . $_SERVER["REMOTE_ADDR"]); ?>
<fieldset id="captcha">
<label for="captcha_response">Bitte geben Sie nebenstehenden Bild-Code in das freie Feld ein (*)</label>
<img src="?page=captcha&id=<?PHP echo $capChallenge; ?>" alt="Geben Sie den Bildcode ein* " />
<input type="text" id="captcha_response" name="captcha_response" />
<input type="hidden" id="captcha_challenge" name="captcha_challenge" value="<?PHP echo $capChallenge; ?>" />
<p id="error_captcha" class="error"></p>
</fieldset>
<hr />
<fieldset id="submit">
<input type="submit" value="Teilnehmen" name="submit"/>
</fieldset>
</form>
</div>
<div id="footer"></div>
</div>
</body>
</html>
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