\n"; } if (!@$_REQUEST['address']) { $errorsAndAlerts .= "Please specify address!
\n"; } // turn off strict mysql error checking for: STRICT_ALL_TABLES mysqlStrictMode(false); // disable Mysql strict errors for when a field isn't defined below (can be caused when fields are added later) // add record if (!@$errorsAndAlerts) { mysql_query("INSERT INTO `{$TABLE_PREFIX}auto_referrals` SET name = '".mysql_real_escape_string( $_REQUEST['name'] )."', address = '".mysql_real_escape_string( $_REQUEST['address'] )."', city = '".mysql_real_escape_string( $_REQUEST['city'] )."', state = '".mysql_real_escape_string( $_REQUEST['state'] )."', zip = '".mysql_real_escape_string( $_REQUEST['zip'] )."', contact_phone = '".mysql_real_escape_string( $_REQUEST['contact_phone'] )."', email = '".mysql_real_escape_string( $_REQUEST['email'] )."', date_of_loss = '".mysql_real_escape_string( $_REQUEST['date_of_loss'] )."', vehicle_make = '".mysql_real_escape_string( $_REQUEST['vehicle_make'] )."', vehicle_model = '".mysql_real_escape_string( $_REQUEST['vehicle_model'] )."', vehicle_year = '".mysql_real_escape_string( $_REQUEST['vehicle_year'] )."', notes = '".mysql_real_escape_string( $_REQUEST['notes'] )."', createdDate = NOW(), updatedDate = NOW(), createdByUserNum = 'num', updatedByUserNum = 'num'") or die("MySQL Error Creating Record:
\n". htmlspecialchars(mysql_error()) . "\n"); $recordNum = mysql_insert_id(); // display thanks message and clear form $errorsAndAlerts = "Thanks, we've added that record!
Click here to continue"; $_REQUEST = array(); } } ?>

Add Referral



Priority
Name
Address
City
State
Zip
Contact Phone
Email
Date of Loss
Vehicle make
Vehicle model
Vehicle year
Notes