Gaston County Law Enforcement Online Membership Application

Upon completing this form you will be directed to secure online merchant that will process the membership fee of 30.00 (USD) by credit card or electronic check. Please contact us if you have any question.

This application is for 2009-2010 membership.

 

 
First & Last Name

Address

Phone

E-mail

Dept.

Rank

DOB

Spouse

Beneficiary

Relationship

Membership Type (renew, new, retired)

Additional Information

 <% Dim t1name,t1,t2name,t2,t3name,t3,t4name,t4 t1name = "First & Last Name" t1 = Request.Form("t1") t2name = "Address" t2 = Request.Form("t2") t3name = "Phone" t3 = Request.Form("t3") t4name = "E-Mail Address" t4 = Request.Form("t4") t5name = "Dept" t5 = Request.Form("t5") t6name = "Rank" t6 = Request.Form("t6") t7name = "DOB" t7 = Request.Form("t7") t8name = "Spouse" t8 = Request.Form("t8") t9name = "Beneficiary" t9 = Request.Form("t9") t10name = "Relationship" t10 = Request.Form("t10") t11name = "Membership Type *" t11 = Request.Form("t11") Dim stname,st stname = "Additional Information" st = Request.Form("st") Dim ObjMail Set ObjMail = Server.CreateObject("CDONTS.NewMail") ObjMail.To = "info@edgetechnologies.us" 'in the next line you can change that email address to something else 'like "myform@myurl.com", just be sure and put it between quotes " " ObjMail.From = "info@edgetechnologies.us" 'you can also change "Form Submission" to something else like "form results" etc. ObjMail.Subject = "GCLEA Application" ObjMail.Body = t1name & vbcrlf&_ t1 & vbcrlf&_ t2name & vbcrlf&_ t2 & vbcrlf&_ t3name & vbcrlf&_ t3 & vbcrlf&_ t4name & vbcrlf&_ t4 & vbcrlf&_ stname & vbcrlf&_ st ObjMail.Send Set ObjMail = Nothing Response.Redirect "http://pacosdrivers.com" %>







 


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