<%@Language=VBScript %> <% Option Explicit%> HEC Subscription Form
<% Dim Conn Dim objSubscriber Dim strConnect Dim strSQL Dim strSubscriber Dim str_title, strfirst_name, strmiddle_name, strsurname, strphone, strfax, stremail, straddress_1, straddress_2, str_suburb, str_state, strpostcode, strcountry, strpayment_method, strcard_type, strcard_number, strexpiry_date, strname_on_card, strusername, strpassword, strconfirm_password, strdate_joined 'start the connection, execute the sql statment and finally close the connection Set Conn = Server.CreateObject("ADODB.Connection") strConnect = "DRIVER={Microsoft Access Driver (*.mdb)};DBQ=" & Server.MapPath("/databases/Subscriber.mdb") conn.open(strConnect) Set objSubscriber = Server.CreateObject("ADODB.Recordset") strSubscriber = Request.Form("Subscriber") %>

HEC Subscription Form

Sign me up for the Healthy Eating Club Subscription $33.00 payable every 6 months

* Denotes compulsory fields

Personal Details
Title
First name *
Middle name
Surname *
Phone
Fax
Email *
Street number
Street name
Suburb
State (Australia only)
Postcode *
Country *
Please enter a username and password to allow you access to restricted parts of this site (max. 8 characters)
Username *
Password *

Payment Details
Note: This is a secure transaction facility. To further protect your privacy, credit card details are discarded once validated.
I wish to pay by
Credit Card Details
Type
Number
Expiry Date
Name on Card
When you click the submit button below your subscription will be processed and an email confirming your details will be forwarded within 24 Hours.

Note: HEC also offers sign-up facilities for those who prefer to use cheque or money order. Please send this form, along with your cheque/money order made payable to Healthy Eating Club Pty Ltd to:

Healthy Eating Club
c/o Emerald Hill Clinic
157 Clarendon St
Southbank
Victoria, 3006
Australia.

 


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