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Moderator: Malcolm
<input type='text' name='description' size='70' maxlength='70'><? if(empty($_POST['description'])) { echo "YOU MUST FILL-IN THE DESCRIPTION-INPUT"; }?><?
$forth = substr($_POST['zip'], 3, 2);
if($forth != "-") {
echo "ERROR";
}
?>

echo "<div id=\"form\" style=\"position:absolute; top:180px; left:156px; z-index:3; padding:0px; width:768px; height: 1207px;\">
<form action='$editFormAction' method='post' name='formInsertRecord' onsubmit='return validateForm(this)'>\n";
print ("<p><input type=\"hidden\" name=\"send\" value=\"true\" />\n");
print ("</p><br>\n");
//Customer Information//
print ("<p class=\"pmtheads\">Customer Information</p><br>\n");
print ("<div class=\"row\"><span class=\"label\">Account Number:</span><span class=\"formw2\"><input name=\"textAccountNumber\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>First Name:</span><span class=\"formw2\"><input name=\"textFirstName\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Last Name:</span><span class=\"formw2\"><input name=\"textLastName\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Address:</span><span class=\"formw2\"><input name=\"textAddress1\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\">Address Line 2:</span><span class=\"formw2\"><input name=\"textAddress2\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>City:</span><span class=\"formw2\"><input name=\"textCity\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>State:</span><span class=\"formSelect\"><span class =\"formw3\"><select name=\"selectSt\">");
foreach ($StateList_array as $ctype1)
{
print("<option>" . $ctype1 . "</option>");
}
print ("</select></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Zip code:</span><span class=\"formw2\"><input name=\"textZip\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Phone number:</span><span class=\"formw2\"><input name=\"textPhone\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>E-mail address:</span><span class=\"formw2\"><input name=\"textEmail\" /></span></div><br>\n");
//Payment Data//
print ("<p class=\"pmtheads\">Payment Information</p><br>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Payment Amount:</span><span class=\"formw2\"><input name=\"textAmount\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\">Payment Attention:</span><span class=\"formw2\"><input name=\"PayAttn\" /></span></div><br>\n");
//Payment Types - Credit//
print ("<div class=\"row3\"><p class=\"pmtheads2\">Please choose one:</span>
<label for=\"Check\">Check</label><span class=\"formw3\"><input name=\"ToggleDivs\" type=\"radio\" value=\"Check\" onClick=\"Toggle('Div1')\" id=\"Div11\"></span>
<label for=\"Credit\">Credit</label><span class=\"formw3\"><input name=\"ToggleDivs\" type=\"radio\" value=\"Credit\" onClick=\"Toggle('Div2')\" id=\"Div22\" ></span>
<label for=\"EasyPay\">EasyPay</label><span class=\"formw3\"><input name=\"ToggleDivs\" type=\"radio\" value=\"EasyPay\" onClick=\"Toggle('Div3')\" id=\"Div33\"></span></div><br>\n");
print ("<div id=\"Div1\" style=\"display:none;\"><br>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Credit Card Type:</span><span class =\"formw3\"><select name=\"selectCCType\"> ");
foreach ($CCList_array as $ctype2)
{
print("<option>" . $ctype2 . "</option>");
}
print ("</select></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Name on Card:</span><span class=\"formw2\"><input name=\"textCCName\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Credit Card Number:</span><span class=\"formw2\"><input name=\"textCCNumber\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Expiration Month and Year:</span><span class =\"formw3\"><select name=\"selectCCExpMonth\">");
foreach ($ExpMonth_array as $ctype3)
{
print("<option>" . $ctype3 . "</option>");
}
print ("</select></span>\ ");
print ("<span class =\"formw3\"><select name=\"selectCCType\">");
foreach ($ExpYear_array as $ctype4)
{
print ("<option>" . $ctype4 . "</option>");
}
print ("</select></span></div></div>\n");
//Payment Types - Check//
print ("<div id=\"Div2\" style=\"display:none;\"><br>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Name on Check:</span><span class=\"formw2\"><input name=\"textCHName\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Check Number:</span><span class=\"formw2\"><input name=\"textCHNumber\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Account Number:</span><span class=\"formw2\"><input name=\"textCHAccountNum\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Routing Number:</span><span class=\"formw2\"><input name=\"textCHRouting\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Bank Name:</span><span class=\"formw2\"><input name=\"textCHBank\" /></span></div>\n");
print ("<div class=\"row\"><span class=\"label\"><span class=\"asterisk\">*</span>Payment Date:</span><span class=\"formw2\"><input name=\"textCHDate\" /></span></div></div><br>\n");
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