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'''''''''''''''''''''''''''''''''''''''''''''''''''''
' VIATEQ CORPORATION
' FORM DEVELOPMENT FILE
' Receives form data and processes it for distribution.
''''''''''''''''''''''''''''''''''''''''''''''''''''
Dim error, justadd, justread, justwrite, newline, ok
Dim knt, f, emsg, r, o, c, other, html, html_end, txt, etxt
Dim greetings
Dim vspc
Dim nlcr
Dim whatisthis1
Dim whatisthis2
Dim htmlheader
Dim htmltail
Dim htmlsubject
Dim htmltitle
Dim part1, part2, part3, part4, part5, part6, part7, part8, part9
Dim member_info
Dim txt_F_Allegations1
Dim txt_F_Telephone_type2
Dim region
Dim region_title
Dim region_email
Dim REMOTE_HOST_NAME
Dim SENDER_EMAIL_ADDRESS
Dim F_Race
Dim bgcolor_left_column
Dim bgcolor_right_column
Dim bgcolor_table
'----------------------------------------
' STEP 1 - Write in the name of your remote host name.
'----------------------------------------
REMOTE_HOST_NAME = "smtp.rcn.com"
'----------------------------------------
' STEP 2 - Write in the name of the email address who is sending the email.
'----------------------------------------
SENDER_EMAIL_ADDRESS = "[email protected]"
SENDER_EMAIL_ADDRESS = "[email protected]"
'----------------------------------------
' Initialize Parts/Sections
'----------------------------------------
bgcolor_left_column = "white"
bgcolor_right_column = "white"
bgcolor_table = "white"
whatisthis1 = ""
whatisthis2 = ""
nlcr = chr(10) & chr(13)
region = 0
justadd = 8
justread = 1
justwrite = 2
error = 0
knt = 0
ok = 0
vspc = " "
part1 = ""
part2 = ""
part3 = ""
part4 = ""
part5 = ""
part6 = ""
part7 = ""
part8 = ""
part9 = ""
greetings = ""
newline = vbCrLF
hline = vbNewLine
emsg = ""
etxt = ""
txt_F_Allegations1 = ""
F_Race = ""
'For Each f In Request.Form
' If Request.Form(f) = "" Then
' error = 0
' End If
'Next
'Response.Write "EMAIL -->" & Request.Form("Email") & "<br><br>"
'Response.Write "OPTION -->" & Request.Form("PICK1") & "<br><br>"
'----------------------------------------
'
'----------------------------------------
F_Form_Language = Request.Form("Form_Language")
F_Fullname1 = Request.Form("Fullname1")
F_Address1 = Request.Form("Address1")
F_City1 = Request.Form("City1")
F_state1 = Request.Form("state1")
F_Zipcode1 = Request.Form("Zipcode1")
F_Telephone1 = Request.Form("Telephone1")
F_Telephone_type1 = Request.Form("Telephone_type1")
F_Email1 = Request.Form("Email1")
F_Allegations1 = Request.Form("Allegations1")
F_Agency_Name1 = Request.Form("Agency_Name1")
F_Agency_POC1 = Request.Form("Agency_POC1")
F_Agency_Telephone1 = Request.Form("Agency_Telephone1")
F_Fullname2 = Request.Form("Fullname2")
F_Address2 = Request.Form("Address2")
F_City2 = Request.Form("City2")
F_state2 = Request.Form("state2")
F_Zipcode2 = Request.Form("Zipcode2")
F_Telephone2 = Request.Form("Telephone2")
F_Telephone_type2 = Request.Form("Telephone_type2")
F_Email2 = Request.Form("Email2")
F_Fullname3 = Request.Form("Fullname3")
F_Address3 = Request.Form("Address3")
F_City3 = Request.Form("City3")
F_state3 = Request.Form("state3")
F_Zipcode3 = Request.Form("Zipcode3")
F_Telephone3 = Request.Form("Telephone3")
F_Dis_Date_Time3 = Request.Form("Dis_Date_Time3")
F_Race41 = Request.Form("Race41")
F_Race42 = Request.Form("Race42")
F_Race43 = Request.Form("Race43")
F_Race44 = Request.Form("Race44")
F_Race45 = Request.Form("Race45")
F_National_Origin4 = Request.Form("National_Origin4")
F_Race4_Tribal_Affiliation4 = Request.Form("Race4_Tribal_Affiliation4")
F_Color4 = Request.Form("Color4")
F_Religion4 = Request.Form("Religion4")
F_Sex4 = Request.Form("Sex4")
F_Sexual_Orientation4 = Request.Form("Sexual_Orientation4")
F_Gender_Identity4 = Request.Form("Gender_Identity4")
F_Inquiring_About_Pay4 = Request.Form("Inquiring_About_Pay4")
F_Discussing_Pay4 = Request.Form("Discussing_Pay4")
F_Disclosing_Pay4 = Request.Form("Disclosing_Pay4")
F_Protected_Veteran_Status4 = Request.Form("Protected_Veteran_Status4")
F_Disability4 = Request.Form("Disability4")
F_Retaliation4 = Request.Form("Retaliation4")
F_Complaint5 = Request.Form("Complaint5")
F_Narrative5 = Request.Form("Narrative5")
F_Treated5 = Request.Form("Treated5")
F_Narrative6 = Request.Form("Narrative6")
F_Attorney5 = Request.Form("Attorney5")
F_Fullname21 = Request.Form("Fullname21")
F_Address21 = Request.Form("Address21")
F_City21 = Request.Form("City21")
F_state21 = Request.Form("state21")
F_Zipcode21 = Request.Form("Zipcode21")
F_Telephone21 = Request.Form("Telephone21")
F_Email21 = Request.Form("Email21")
F_Print_Signature = Request.Form("Print_Signature")
F_Print_Signature_Date = Request.Form("Print_Signature_Date")
'----------------------------------------
'
'----------------------------------------
Function Error_Text(txt)
etxt = etxt & txt & "<br>"
end function
'----------------------------------------
' Checking input values
'----------------------------------------
if F_Fullname1 = "" then
Error_Text("- Blank Name")
end if
if F_Address1 = "" then
Error_Text("- Blank Address")
end if
if F_City1 = "" then
Error_Text("- Blank City")
end if
if F_state1 = "" then
Error_Text("- Please select a state from the dropdown")
end if
if F_Zipcode1 = "" then
Error_Text("- Blank Zipcode")
end if
if F_Telephone1 = "" then
Error_Text("- Blank Telephone #")
else
Select Case F_Telephone_type1
Case 1
txt_F_Telephone_type1 = ""
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' checked='checked' disabled='disabled'>Home"
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' disabled='disabled'>Work"
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' disabled='disabled'>Cell"
Case 2
txt_F_Telephone_type1 = ""
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' disabled='disabled'>Home"
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' checked='checked' disabled='disabled'>Work"
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' disabled='disabled'>Cell"
Case 3
txt_F_Telephone_type1 = ""
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' disabled='disabled'>Home"
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' disabled='disabled'>Work"
txt_F_Telephone_type1 = txt_F_Telephone_type1 & "<input type='radio' value='1' name='Tele_type' checked='checked' disabled='disabled'>Cell"
End Select
end if
Select Case F_Telephone_type2
Case 1
txt_F_Telephone_type2 = ""
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' checked='checked' disabled='disabled'>Home"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Work"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Cell"
Case 2
txt_F_Telephone_type2 = txt_F_Telephone_type2 = ""
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Home"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' checked='checked' disabled='disabled'>Work"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Cell"
Case 3
txt_F_Telephone_type2 = ""
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Home"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Work"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' checked='checked' disabled='disabled'>Cell"
Case else
txt_F_Telephone_type2 = ""
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Home"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Work"
txt_F_Telephone_type2 = txt_F_Telephone_type2 & "<input value='2' type='radio' name='Tele_type2' disabled='disabled'>Cell"
End Select
if F_Email1 = "" then
Error_Text("- Blank Email Address")
end if
if F_Allegations1 = 1 then
F_Allegations1 = ""
F_Allegations1 = F_Allegations1 & "<input type='radio' value='1' name='Allegations' checked='checked' disabled='disabled'>Yes"
F_Allegations1 = F_Allegations1 & "<input type='radio' value='1' name='Allegations' disabled='disabled'>No"
if F_Agency_Name1 = "" then
Error_Text("- Blank Agency Name")
end if
if F_Agency_POC1 = "" then
Error_Text("- Blank Agency Point of Contact")
end if
if F_Agency_Telephone1 = "" then
Error_Text("- Blank Agency Telephone Number")
end if
else
F_Allegations1 = ""
F_Allegations1 = F_Allegations1 & "<input type='radio' value='1' name='Allegations' disabled='disabled'>Yes"
F_Allegations1 = F_Allegations1 & "<input type='radio' value='1' name='Allegations' checked='checked' disabled='disabled'>No"
F_Agency_Name1 = " "
F_Agency_POC1 = " "
F_Agency_Telephone1 = " "
end if
if F_Print_Signature = "" then
Error_Text("- Please sign document")
else
if F_Print_Signature_Date = "" then
Error_Text("- Blank Signature Date")
end if
end if
if F_Fullname2 <> "" then
if F_Telephone2 = "" then
Error_Text("- Blank Alternate Telephone #")
end if
end if
if len(F_Race4_Tribal_Affiliation4) < 1 then
F_Race4_Tribal_Affiliation4 = "None"
end if
'----------------------------------------
' RACE
'----------------------------------------
'----------------------------------------
' American Indian or Alaska Native
'----------------------------------------
if F_Race41 = "1" then
F_Race41 = "<tr><td valign=top>"
F_Race41 = F_Race41 & "<input type='checkbox' name='race41' value='1' checked='checked' disabled='disabled'/>"
F_Race41 = F_Race41 & "</td><td valign=center>"
F_Race41 = F_Race41 & "American Indian or Alaska Native (Tribal Affiliation:"
F_Race41 = F_Race41 & F_Race4_Tribal_Affiliation4
F_Race41 = F_Race41 & "</td></tr>"
Else
F_Race41 = "<tr><td valign=top>"
F_Race41 = F_Race41 & "<input type='checkbox' name='race41' value='1' disabled='disabled'/>"
F_Race41 = F_Race41 & "</td><td valign=center>"
F_Race41 = F_Race41 & "American Indian or Alaska Native (Tribal Affiliation:"
F_Race41 = F_Race41 & F_Race4_Tribal_Affiliation4
F_Race41 = F_Race41 & "</td></tr>"
end if
'----------------------------------------
' Asian
'----------------------------------------
if F_Race42 = "1" then
F_Race42 = "<tr><td valign=top>"
F_Race42 = F_Race42 & "<input type='checkbox' name='race42' value='1' checked='checked' disabled='disabled'/>"
F_Race42 = F_Race42 & "</td><td valign=center>"
F_Race42 = F_Race42 & "Asian"
F_Race42 = F_Race42 & "</td></tr>"
Else
F_Race42 = "<tr><td valign=top>"
F_Race42 = F_Race42 & "<input type='checkbox' name='race42' value='1' disabled='disabled'/>"
F_Race42 = F_Race42 & "</td><td valign=center>"
F_Race42 = F_Race42 & "Asian"
F_Race42 = F_Race42 & "</td></tr>"
end if
'----------------------------------------
' Black or African American
'----------------------------------------
if F_Race43 = "1" then
F_Race43 = "<tr><td valign=top>"
F_Race43 = F_Race43 & "<input type='checkbox' name='race43' value='1' checked='checked' disabled='disabled'/>"
F_Race43 = F_Race43 & "</td><td valign=center>"
F_Race43 = F_Race43 & "Black or African American"
F_Race43 = F_Race43 & "</td></tr>"
Else
F_Race43 = "<tr><td valign=top>"
F_Race43 = F_Race43 & "<input type='checkbox' name='race43' value='1' disabled='disabled'/>"
F_Race43 = F_Race43 & "</td><td valign=center>"
F_Race43 = F_Race43 & "Black or African American"
F_Race43 = F_Race43 & "</td></tr>"
end if
'----------------------------------------
' Native Hawaiian or Other Pacific Islander
'----------------------------------------
if F_Race44 = "1" then
F_Race44 = "<tr><td valign=top>"
F_Race44 = F_Race44 & "<input type='checkbox' name='race44' value='1' checked='checked' disabled='disabled'/>"
F_Race44 = F_Race44 & "</td><td valign=center>"
F_Race44 = F_Race44 & "Native Hawaiian or Other Pacific Islander"
F_Race44 = F_Race44 & "</td></tr>"
Else
F_Race44 = "<tr><td valign=top>"
F_Race44 = F_Race44 & "<input type='checkbox' name='race44' value='1' disabled='disabled'/>"
F_Race44 = F_Race44 & "</td><td valign=center>"
F_Race44 = F_Race44 & "Native Hawaiian or Other Pacific Islander"
F_Race44 = F_Race44 & "</td></tr>"
end if
'----------------------------------------
' White
'----------------------------------------
if F_Race45 = "1" then
F_Race45 = "<tr><td valign=top>"
F_Race45 = F_Race45 & "<input type='checkbox' name='race45' value='1' checked='checked' disabled='disabled'/>"
F_Race45 = F_Race45 & "</td><td valign=center>"
F_Race45 = F_Race45 & "White"
F_Race45 = F_Race45 & "</td></tr>"
Else
F_Race45 = "<tr><td valign=top>"
F_Race45 = F_Race45 & "<input type='checkbox' name='race45' value='1' disabled='disabled'/>"
F_Race45 = F_Race45 & "</td><td valign=center>"
F_Race45 = F_Race45 & "White"
F_Race45 = F_Race45 & "</td></tr>"
end if
'----------------------------------------
' National_Origin
'----------------------------------------
if F_National_Origin4 = "1" then
F_National_Origin4 = "<tr>"
F_National_Origin4 = F_National_Origin4 & "<td valign=top>"
F_National_Origin4 = F_National_Origin4 & "<input type='checkbox' name='National_Origin' value='1' checked='checked' disabled='disabled'/>"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "<td valign=center>"
F_National_Origin4 = F_National_Origin4 & "Hispanic or Latino"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "</tr>"
F_National_Origin4 = F_National_Origin4 & "<tr>"
F_National_Origin4 = F_National_Origin4 & "<td valign=top>"
F_National_Origin4 = F_National_Origin4 & "<input type='checkbox' name='National_Origin_Other' value='1' disabled='disabled'/>"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "<td valign=center>"
F_National_Origin4 = F_National_Origin4 & "Other"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "</tr>"
Else
F_National_Origin4 = "<tr>"
F_National_Origin4 = F_National_Origin4 & "<td valign=top>"
F_National_Origin4 = F_National_Origin4 & "<input type='checkbox' name='National_Origin' value='1' disabled='disabled'/>"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "<td valign=center>"
F_National_Origin4 = F_National_Origin4 & "Hispanic or Latino"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "</tr>"
F_National_Origin4 = F_National_Origin4 & "<tr>"
F_National_Origin4 = F_National_Origin4 & "<td valign=top>"
F_National_Origin4 = F_National_Origin4 & "<input type='checkbox' name='National_Origin_Other' value='1' checked='checked' disabled='disabled'/>"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "<td valign=center>"
F_National_Origin4 = F_National_Origin4 & "Other"
F_National_Origin4 = F_National_Origin4 & "</td>"
F_National_Origin4 = F_National_Origin4 & "</tr>"
end if
'----------------------------------------
' Color
'----------------------------------------
if F_Color4 = "1" then
F_Color4 = "<tr><td valign=top>"
F_Color4 = F_Color4 & "<input type='checkbox' name='Color' value='1' checked='checked' disabled='disabled'/>"
F_Color4 = F_Color4 & "</td><td valign=center>"
F_Color4 = F_Color4 & "<b>Color</b>"
F_Color4 = F_Color4 & "</td></tr>"
Else
F_Color4 = "<tr><td valign=top>"
F_Color4 = F_Color4 & "<input type='checkbox' name='Color' value='1' disabled='disabled'/>"
F_Color4 = F_Color4 & "</td><td valign=center>"
F_Color4 = F_Color4 & "<b>Color</b>"
F_Color4 = F_Color4 & "</td></tr>"
end if
'----------------------------------------
' Religion
'----------------------------------------
if F_Religion4 = "1" then
F_Religion4 = "<tr><td valign=top>"
F_Religion4 = F_Religion4 & "<input type='checkbox' name='Religion' value='1' checked='checked' disabled='disabled'/>"
F_Religion4 = F_Religion4 & "</td><td valign=center>"
F_Religion4 = F_Religion4 & "<b>Religion</b>"
F_Religion4 = F_Religion4 & "</td></tr>"
Else
F_Religion4 = "<tr><td valign=top>"
F_Religion4 = F_Religion4 & "<input type='checkbox' name='Religion' value='1' disabled='disabled'/>"
F_Religion4 = F_Religion4 & "</td><td valign=center>"
F_Religion4 = F_Religion4 & "<b>Religion</b>"
F_Religion4 = F_Religion4 & "</td></tr>"
end if
'----------------------------------------
' Sex
'----------------------------------------
if F_Sex4 = "1" then
F_Sex4 = "<tr><td valign=top>"
F_Sex4 = F_Sex4 & "<input type='checkbox' name='Sex' value='1' checked='checked' disabled='disabled'/>"
F_Sex4 = F_Sex4 & "</td><td valign=center>"
F_Sex4 = F_Sex4 & "<b>Sex</b>"
F_Sex4 = F_Sex4 & "</td></tr>"
Else
F_Sex4 = "<tr><td valign=top>"
F_Sex4 = F_Sex4 & "<input type='checkbox' name='Sex' value='1' disabled='disabled'/>"
F_Sex4 = F_Sex4 & "</td><td valign=center>"
F_Sex4 = F_Sex4 & "<b>Sex</b>"
F_Sex4 = F_Sex4 & "</td></tr>"
end if
'----------------------------------------
' Sexual_Orientation
'----------------------------------------
if F_Sexual_Orientation4 = "1" then
F_Sexual_Orientation4 = "<tr><td valign=top>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "<input type='checkbox' name='Sexual_Orientation' value='1' checked='checked' disabled='disabled'/>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "</td><td valign=center>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "<b>Sexual Orientation</b>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "</td></tr>"
Else
F_Sexual_Orientation4 = "<tr><td valign=top>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "<input type='checkbox' name='Sexual_Orientation' value='1' disabled='disabled'/>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "</td><td valign=center>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "<b>Sexual Orientation</b>"
F_Sexual_Orientation4 = F_Sexual_Orientation4 & "</td></tr>"
end if
'----------------------------------------
' F_Gender_Identity4
'----------------------------------------
if F_Gender_Identity4 = "1" then
F_Gender_Identity4 = "<tr><td valign=top>"
F_Gender_Identity4 = F_Gender_Identity4 & "<input type='checkbox' name='Gender' value='1' checked='checked' disabled='disabled'/>"
F_Gender_Identity4 = F_Gender_Identity4 & "</td><td valign=center>"
F_Gender_Identity4 = F_Gender_Identity4 & "<b>Gender Identity</b>"
F_Gender_Identity4 = F_Gender_Identity4 & "</td></tr>"
Else
F_Gender_Identity4 = "<tr><td valign=top>"
F_Gender_Identity4 = F_Gender_Identity4 & "<input type='checkbox' name='Gender' value='1' disabled='disabled'/>"
F_Gender_Identity4 = F_Gender_Identity4 & "</td><td valign=center>"
F_Gender_Identity4 = F_Gender_Identity4 & "<b>Gender Identity</b>"
F_Gender_Identity4 = F_Gender_Identity4 & "</td></tr>"
end if
'----------------------------------------
' Inquiring_About_Pay
'----------------------------------------
if F_Inquiring_About_Pay4 = "1" then
F_Inquiring_About_Pay4 = ""
F_Inquiring_About_Pay4 = "<tr><td valign=top>"
F_Inquiring_About_Pay4 = F_Inquiring_About_Pay4 & "<input type='checkbox' name='Inquiring_About_Pay' value='1' checked='checked' disabled='disabled'/>"
F_Inquiring_About_Pay4 = F_Inquiring_About_Pay4 & "</td><td valign=center><b>Inquiring About Pay</b></td></tr>"
Else
F_Inquiring_About_Pay4 = ""
F_Inquiring_About_Pay4 = "<tr><td valign=top>"
F_Inquiring_About_Pay4 = F_Inquiring_About_Pay4 & "<input type='checkbox' name='Inquiring_About_Pay' value='1' disabled='disabled'/>"
F_Inquiring_About_Pay4 = F_Inquiring_About_Pay4 & "</td><td valign=center><b>Inquiring About Pay</b></td></tr>"
end if
'----------------------------------------
' Discussing Pay
'----------------------------------------
if F_Discussing_Pay4 = "1" then
F_Discussing_Pay4 = ""
F_Discussing_Pay4 = "<tr><td valign=top>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "<input type='checkbox' name='Discussing_Pay' value='1' checked='checked' disabled='disabled'/>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "</td><td valign=center>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "<b>Discussing Pay</b>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "</td></tr>"
Else
F_Discussing_Pay4 = ""
F_Discussing_Pay4 = "<tr><td valign=top>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "<input type='checkbox' name='Discussing_Pay' value='1' disabled='disabled'/>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "</td><td valign=center>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "<b>Discussing Pay</b>"
F_Discussing_Pay4 = F_Discussing_Pay4 & "</td></tr>"
end if
'----------------------------------------
' Disclosing Pay
'----------------------------------------
if F_Disclosing_Pay4 = "1" then
F_Disclosing_Pay4 = ""
F_Disclosing_Pay4 = "<tr><td valign=top>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "<input type='checkbox' name='Disclosing_Pay' value='1' checked='checked' disabled='disabled'/>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "</td><td valign=center>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "<b>Disclosing Pay</b>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "</td></tr>"
Else
F_Disclosing_Pay4 = ""
F_Discussing_Pay4 = "<tr><td valign=top>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "<input type='checkbox' name='Disclosing_Pay' value='1' disabled='disabled'/>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "</td><td valign=center>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "<b>Disclosing Pay</b>"
F_Disclosing_Pay4 = F_Disclosing_Pay4 & "</td></tr>"
end if
'----------------------------------------
' Protected Veteran Status
'----------------------------------------
if F_Protected_Veteran_Status4 = "1" then
F_Protected_Veteran_Status4 = "<tr><td valign=top>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "<input type='checkbox' name='Veteran_Status' value='1' checked='checked' disabled='disabled'/>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "</td><td valign=center>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "<b>Protected Veteran Status</b>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "</td></tr>"
Else
F_Protected_Veteran_Status4 = "<tr><td valign=top>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "<input type='checkbox' name='Veteran_Status' value='1' disabled='disabled'/>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "</td><td valign=center>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "<b>Protected Veteran Status</b>"
F_Protected_Veteran_Status4 = F_Protected_Veteran_Status4 & "</td></tr>"
end if
'----------------------------------------
' Disability
'----------------------------------------
if F_Disability4 = "1" then
F_Disability4 = "<tr><td valign=top>"
F_Disability4 = F_Disability4 & "<input type='checkbox' name='Disability' value='1' checked='checked' disabled='disabled'/>"
F_Disability4 = F_Disability4 & "</td><td valign=center>"
F_Disability4 = F_Disability4 & "<b>Disability</b>"
F_Disability4 = F_Disability4 & "</td></tr>"
Else
F_Disability4 = "<tr><td valign=top>"
F_Disability4 = F_Disability4 & "<input type='checkbox' name='Disability' value='1' disabled='disabled'/>"
F_Disability4 = F_Disability4 & "</td><td valign=center>"
F_Disability4 = F_Disability4 & "<b>Disability</b>"
F_Disability4 = F_Disability4 & "</td></tr>"
end if
'----------------------------------------
' Retaliation
'----------------------------------------
if F_Retaliation4 = "1" then
F_Retaliation4 = "<tr><td valign=top>"
F_Retaliation4 = F_Retaliation4 & "<input type='checkbox' name='Retaliation' value='1' checked='checked' disabled='disabled'/>"
F_Retaliation4 = F_Retaliation4 & "</td><td valign=center>"
F_Retaliation4 = F_Retaliation4 & "<b>Retaliation</b>"
F_Retaliation4 = F_Retaliation4 & "</td></tr>"
Else
F_Retaliation4 = "<tr><td valign=top>"
F_Retaliation4 = F_Retaliation4 & "<input type='checkbox' name='Retaliation' value='1' disabled='disabled'/>"
F_Retaliation4 = F_Retaliation4 & "</td><td valign=center>"
F_Retaliation4 = F_Retaliation4 & "<b>Retaliation</b>"
F_Retaliation4 = F_Retaliation4 & "</td></tr>"
end if
'----------------------------------------
' Complaint
'----------------------------------------
if F_Complaint5 = "1" then
F_Complaint5 = "<tr><td valign=top>"
F_Complaint5 = F_Retaliation4 & "<input type='checkbox' name='Retaliation' value='1' checked='checked' disabled='disabled'/>"
F_Complaint5 = F_Retaliation4 & "</td><td valign=center>"
F_Complaint5 = F_Retaliation4 & "<b>Retaliation</b>"
F_Complaint5 = F_Retaliation4 & "</td></tr>"
Else
F_Retaliation4 = "<tr><td valign=top>"
F_Retaliation4 = F_Retaliation4 & "<input type='checkbox' name='Retaliation' value='1' disabled='disabled'/>"
F_Retaliation4 = F_Retaliation4 & "</td><td valign=center>"
F_Retaliation4 = F_Retaliation4 & "<b>Retaliation</b>"
F_Retaliation4 = F_Retaliation4 & "</td></tr>"
end if
Select Case F_Complaint5
case "Internet"
F_Complaint5 = ""
F_Complaint5 = F_Complaint5 & "<tr><td>"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint1' value='1' checked='checked' disabled='disabled'/>Internet"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint2' value='1' disabled='disabled'/>Poster"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint3' value='1' disabled='disabled'/>Community Organization"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint4' value='1' disabled='disabled'/>OFCCP Meeting/Event"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint5' value='1' disabled='disabled'/>Brochure"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint6' value='1' disabled='disabled'/>Other"
F_Complaint5 = F_Complaint5 & "</td>"
F_Complaint5 = F_Complaint5 & "</tr>"
case "Poster"
F_Complaint5 = ""
F_Complaint5 = F_Complaint5 & "<tr><td>"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint1' value='1' disabled='disabled'/>Internet"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint2' value='1' checked='checked' disabled='disabled'/>Poster"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint3' value='1' disabled='disabled'/>Community Organization"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint4' value='1' disabled='disabled'/>OFCCP Meeting/Event"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint5' value='1' disabled='disabled'/>Brochure"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint6' value='1' disabled='disabled'/>Other"
F_Complaint5 = F_Complaint5 & "</td>"
F_Complaint5 = F_Complaint5 & "</tr>"
case "Community Organization"
F_Complaint5 = ""
F_Complaint5 = F_Complaint5 & "<tr><td>"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint1' value='1' disabled='disabled'/>Internet"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint2' value='1' disabled='disabled'/>Poster"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint3' value='1' checked='checked' disabled='disabled'/>Community Organization"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint4' value='1' disabled='disabled'/>OFCCP Meeting/Event"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint5' value='1' disabled='disabled'/>Brochure"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint6' value='1' disabled='disabled'/>Other"
F_Complaint5 = F_Complaint5 & "</td>"
F_Complaint5 = F_Complaint5 & "</tr>"
case "OFCCP Meeting/Event"
F_Complaint5 = ""
F_Complaint5 = F_Complaint5 & "<tr><td>"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint1' value='1' disabled='disabled'/>Internet"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint2' value='1' disabled='disabled'/>Poster"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint3' value='1' disabled='disabled'/>Community Organization"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint4' value='1' checked='checked' disabled='disabled'/>OFCCP Meeting/Event"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint5' value='1' disabled='disabled'/>Brochure"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint6' value='1' disabled='disabled'/>Other"
F_Complaint5 = F_Complaint5 & "</td>"
F_Complaint5 = F_Complaint5 & "</tr>"
case "Brochure"
F_Complaint5 = ""
F_Complaint5 = F_Complaint5 & "<tr><td>"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint1' value='1' disabled='disabled'/>Internet"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint2' value='1' disabled='disabled'/>Poster"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint3' value='1' disabled='disabled'/>Community Organization"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint4' value='1' disabled='disabled'/>OFCCP Meeting/Event"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint5' value='1' checked='checked' disabled='disabled'/>Brochure"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint6' value='1' disabled='disabled'/>Other"
F_Complaint5 = F_Complaint5 & "</td>"
F_Complaint5 = F_Complaint5 & "</tr>"
case "Other"
F_Complaint5 = ""
F_Complaint5 = F_Complaint5 & "<tr><td>"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint1' value='1' disabled='disabled'/>Internet"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint2' value='1' disabled='disabled'/>Poster"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint3' value='1' disabled='disabled'/>Community Organization"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint4' value='1' disabled='disabled'/>OFCCP Meeting/Event"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint5' value='1' disabled='disabled'/>Brochure"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint6' value='1' checked='checked' disabled='disabled'/>Other"
F_Complaint5 = F_Complaint5 & "</td>"
F_Complaint5 = F_Complaint5 & "</tr>"
case else
F_Complaint5 = ""
F_Complaint5 = F_Complaint5 & "<tr><td>"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint1' value='1' checked='checked' disabled='disabled'/>Internet"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint2' value='1' checked='checked' disabled='disabled'/>Poster"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint3' value='1' checked='checked' disabled='disabled'/>Community Organization"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint4' value='1' checked='checked' disabled='disabled'/>OFCCP Meeting/Event"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint5' value='1' checked='checked' disabled='disabled'/>Brochure"
F_Complaint5 = F_Complaint5 & "<input type='checkbox' name='Complaint6' value='1' checked='checked' disabled='disabled'/>Other"
F_Complaint5 = F_Complaint5 & "</td>"
F_Complaint5 = F_Complaint5 & "</tr>"
End Select
if F_Attorney5 = "You" then
F_Attorney5 = ""
F_Attorney5 = F_Attorney5 & "<input type='radio' value='1' name='Attorney5' checked='checked' disabled='disabled'>You"
F_Attorney5 = F_Attorney5 & "<input type='radio' value='1' name='Attorney5' disabled='disabled'>Your Representative"
else
F_Attorney5 = ""
F_Attorney5 = F_Attorney5 & "<input type='radio' value='1' name='Attorney5' disabled='disabled'>You"
F_Attorney5 = F_Attorney5 & "<input type='radio' value='1' name='Attorney5' checked='checked' disabled='disabled'>Your Representative"
end if
'----------------------------------------
' if values are clean then continue
'----------------------------------------
if etxt = "" THEN
'Response.Write txt
htmlsubject = "OFCCP Complaint Form"
htmltitle = "Complaint Involving Employment Discrimination by a Federal Contractor or Subcontractor" & "<br><br>"
htmlheader = "<html>"
htmlheader = htmlheader & "<head>"
htmlheader = htmlheader & "<style>"
htmlheader = htmlheader & "body {background-color: white;}"
htmlheader = htmlheader & "h1 {"
htmlheader = htmlheader & "color: black;"
htmlheader = htmlheader & "font-family: Calibri, Candara, Segoe, 'Segoe UI', Optima, Arial, sans-serif;"
htmlheader = htmlheader & "font-size: 14px;"
htmlheader = htmlheader & "font-style: normal;"
htmlheader = htmlheader & "font-variant: normal;"
htmlheader = htmlheader & "font-weight: 500;"
htmlheader = htmlheader & "line-height: 15px;"
htmlheader = htmlheader & "}"
htmlheader = htmlheader & "h2 {"
htmlheader = htmlheader & "color: black;"
htmlheader = htmlheader & "font-family: Calibri, Candara, Segoe, 'Segoe UI', Optima, Arial, sans-serif;"
htmlheader = htmlheader & "font-size: 22px;"
htmlheader = htmlheader & "font-style: normal;"
htmlheader = htmlheader & "font-variant: normal;"
htmlheader = htmlheader & "font-weight: 500;"
htmlheader = htmlheader & "line-height: 20px;"
htmlheader = htmlheader & "}"
htmlheader = htmlheader & "h3 {"
htmlheader = htmlheader & "color: black;"
htmlheader = htmlheader & "font-family: Calibri, Candara, Segoe, 'Segoe UI', Optima, Arial, sans-serif;"
htmlheader = htmlheader & "font-size: 22px;"
htmlheader = htmlheader & "font-style: normal;"
htmlheader = htmlheader & "font-variant: normal;"
htmlheader = htmlheader & "font-weight: 500;"
htmlheader = htmlheader & "line-height: 11px;"
htmlheader = htmlheader & "}"
htmlheader = htmlheader & ".table_font {"
htmlheader = htmlheader & "color: black;"
htmlheader = htmlheader & "font-family: Calibri, Candara, Segoe, 'Segoe UI', Optima, Arial, sans-serif;"
htmlheader = htmlheader & "font-size: 12px;"
htmlheader = htmlheader & "font-style: normal;"
htmlheader = htmlheader & "font-variant: normal;"
htmlheader = htmlheader & "font-weight: 500;"
htmlheader = htmlheader & "line-height: 11px;"
htmlheader = htmlheader & "}"
htmlheader = htmlheader & ".table_font_title {"
htmlheader = htmlheader & "color: black;"
htmlheader = htmlheader & "font-family: Calibri, Candara, Segoe, 'Segoe UI', Optima, Arial, sans-serif;"
htmlheader = htmlheader & "font-size: 14px;"
htmlheader = htmlheader & "font-style: normal;"
htmlheader = htmlheader & "font-variant: normal;"
htmlheader = htmlheader & "font-weight: 500;"
htmlheader = htmlheader & "line-height: 15px;"
htmlheader = htmlheader & "}"
htmlheader = htmlheader & "input {"
htmlheader = htmlheader & "border: 0;"
htmlheader = htmlheader & "outline: 0;"
htmlheader = htmlheader & "background: transparent;"
htmlheader = htmlheader & "border-bottom: 1px solid black;"
htmlheader = htmlheader & "}"
htmlheader = htmlheader & "textarea {"
htmlheader = htmlheader & "border: 0;"
htmlheader = htmlheader & "outline: 0;"
htmlheader = htmlheader & "background: #F0F8FF;"
htmlheader = htmlheader & "border-bottom: 1px solid black;"
htmlheader = htmlheader & "}"
htmlheader = htmlheader & "</style> "
htmlheader = " </head>"
htmlheader = "<body>"
htmlheader = htmlheader & "<table bgcolor='white' width='800px' border='0' cellspacing='0' cellpadding='0' align='center'>"
htmlheader = htmlheader & "<!------------------------"
htmlheader = htmlheader & "FORM TITLE"
htmlheader = htmlheader & "------------------------->"
htmlheader = htmlheader & "<tr>"
htmlheader = htmlheader & "<td valign='top' align=left>"
htmlheader = htmlheader & "<img src='http://www.conceptlabs.com/viateq/demo/icon-dol.jpg' align='top' width='45' border='0' alt='Department of Labor' title='Department of Labor'><img src='http://www.conceptlabs.com/viateq/demo/icon-ofccp.jpg' align='top' width='155' border='0' alt='Office of Federal Contract Compliance Programs' title='Office of Federal Contract Compliance Programs'>"
htmlheader = htmlheader & "</td>"
htmlheader = htmlheader & "<td valign='top' align=right>"
htmlheader = htmlheader & "<big><b>Complaint Involving Employment Discrimination by a<br>Federal Contractor or Subcontractor</b></big></td>"
htmlheader = htmlheader & "</tr><tr><td></td></tr>"
htmlheader = htmlheader & "</table><br>"
htmlheader = htmlheader & "<table bgcolor='white' width='800px' border='1' cellspacing='0' cellpadding='0' align='center'>"
part1 = ""
part1 = part1 & "<!------------------------"
part1 = part1 & "SECTION 1"
part1 = part1 & "------------------------->"
part1 = part1 & "<tr>"
part1 = part1 & "<td width='200' align=center><b>How can we reach you?</b></td>"
part1 = part1 & "<td width='600' >"
part1 = part1 & "<table border='0' cellspacing='0' cellpadding='10'>"
part1 = part1 & "<tr><td>Name (First, Middle, Last):<input size= '50' type='text' name='name' readonly value='" & F_Fullname1 & "'></td></tr>"
part1 = part1 & "<tr><td>Street Address:<input size= '50' type='text' name='address' readonly value='" & F_Address1 & "'></td></tr>"
part1 = part1 & "<tr><td>City:<input size= '30' type='text' name='city' readonly value='" & F_City1 & "'>"
part1 = part1 & "State:<input size= '3' type='text' name='state' readonly value='" & F_state1 & "'>"
part1 = part1 & "Zip Code:<input size= '10' type='text' name='zip' readonly value='" & F_Zipcode1 & "'></td></tr>"
part1 = part1 & "<tr><td>Telephone Number:" & F_Telephone1 & " " & txt_F_Telephone_type1 & "</td></tr>"
part1 = part1 & "<tr><td>E-mail:<input size= '30' type='text' name='email' readonly value='" & F_Email1 & "'><br></td></tr>"
part1 = part1 & "<tr><td>Have you filed these allegations of employment discrimination with another federal or local agency?" & F_Allegations1 & "</td></tr>"
part1 = part1 & "<tr><td>If yes, which agency:<input size= '10' type='text' name='agency' readonly value='" & F_Agency_Name1 & "'></td></tr>"
part1 = part1 & "<tr><td>Contact Name:<input size= '30' type='text' name='contact' readonly value='" & F_Agency_POC1 & "'>"
part1 = part1 & "Phone Number:<input size= '10' type='text' name='phone' readonly value='" & F_Agency_Telephone1 & "'></td></tr>"
part1 = part1 & "</table>"
part1 = part1 & "</td>"
part1 = part1 & "</tr>"
part2 = ""
part2 = part2 & "<!------------------------"
part2 = part2 & "SECTION 2"
part2 = part2 & "------------------------->"
part2 = part2 & "<tr>"
part2 = part2 & "<td align=center><b>Who can we contact if <br>we cannot reach you?</b></td>"
part2 = part2 & "<td>"
part2 = part2 & "<table border='0' cellspacing='0' cellpadding='10'>"
part2 = part2 & "<tr><td>Name (First, Middle, Last):<input size= '50' type='text' name='name' readonly value='" & F_Fullname2 & "'></td></tr>"
part2 = part2 & "<tr><td>Street Address:<input size= '50' type='text' name='address' readonly value='" & F_Address2 & "'></td></tr>"
part2 = part2 & "<tr><td>City:<input size= '30' type='text' name='city' readonly value='" & F_City2 & "'>"
part2 = part2 & "State:<input size= '3' type='text' name='state' readonly value='" & F_state2 & "'>"
part2 = part2 & "Zip Code:<input size= '10' type='text' name='zip' readonly value='" & F_Zipcode2 & "'></td></tr>"
part2 = part2 & "<tr><td>Telephone Number:" & F_Telephone2 & " " & txt_F_Telephone_type2 & "</td></tr>"
part2 = part2 & "<tr><td>E-mail:<input size= '30' type='text' name='email' readonly value='" & F_Email2 & "'></td></tr>"
part2 = part2 & "</table>"
part2 = part2 & "</td>"
part2 = part2 & "</tr>"
part3 = ""
part3 = part3 & "<!------------------------"
part3 = part3 & "SECTION 3"
part3 = part3 & "------------------------->"
part3 = part3 & "<tr>"
part3 = part3 & "<td align=center><b>What is the name of <br>the employer that you believe <br>discriminated or retaliated<br> against you?</b></td>"
part3 = part3 & "<td >"
part3 = part3 & "<table border='0' cellspacing='0' cellpadding='5'>"
part3 = part3 & "<tr><td>Employer Name:<input size= '50' type='text' name='name' readonly value='" & F_Fullname3 & "'></td></tr>"
part3 = part3 & "<tr><td>Street Address:<input size= '50' type='text' name='address' readonly value='" & F_Address3 & "'></td></tr>"
part3 = part3 & "<tr><td>City:<input size= '30' type='text' name='city' readonly value='" & F_City3 & "'>"
part3 = part3 & "State:<input size= '3' type='text' name='state' readonly value='" & F_state3 & "'>"
part3 = part3 & "Zip Code:<input size= '10' type='text' name='zip' readonly value='" & F_Zipcode3 & "'></td></tr>"
part3 = part3 & "<tr><td>Telephone Number:" & F_Telephone3 & "</td></tr>"
part3 = part3 & "<tr><td>E-mail:<input size= '30' type='text' name='email' readonly value='" & F_Email3 & "'></td></tr>"
part3 = part3 & "</table>"
part3 = part3 & "</td>"
part3 = part3 & "</tr>"
part4 = ""
part4 = part4 & "<!------------------------"
part4 = part4 & "SECTION 4"
part4 = part4 & "------------------------->"
part4 = part4 & "<tr>"
part4 = part4 & "<td align=center><b>Why do you believe<br> your employer discriminated<br> or retaliated against you? </b></td>"
part4 = part4 & "<td>"
part4 = part4 & "<table width='100%' border='0' cellspacing='0' cellpadding='5'>"
part4 = part4 & "<tr>"
part4 = part4 & "<td valign='top' width='25%'>"
part4 = part4 & "<table width='100%' border='0' cellspacing='0' cellpadding='0'>"
part4 = part4 & "<tr><td><b>Race</b></td></tr>"
part4 = part4 & F_Race41
part4 = part4 & F_Race42
part4 = part4 & F_Race43
part4 = part4 & F_Race44
part4 = part4 & F_Race45
part4 = part4 & "</table>"
part4 = part4 & "</td>"
part4 = part4 & "<td valign='top' width='25%'>"
part4 = part4 & "<table width='100%' border='0' cellspacing='5' cellpadding='0' cols=2>"
part4 = part4 & "<tr><th colspan=2><b>National Origin</b></th></tr>"
part4 = part4 & F_National_Origin4
part4 = part4 & "<tr><th colspan=2><br></th></tr>"
part4 = part4 & F_Color4
part4 = part4 & F_Religion4
part4 = part4 & F_Sex4
part4 = part4 & "</table>"
part4 = part4 & "</td>"
part4 = part4 & "<td valign='top' width='25%'>"
part4 = part4 & "<table width='100%' border='0' cellspacing='5' cellpadding='0'>"
part4 = part4 & F_Sexual_Orientation4
part4 = part4 & F_Gender_Identity4
part4 = part4 & F_Inquiring_About_Pay4
part4 = part4 & F_Discussing_Pay4
part4 = part4 & F_Disclosing_Pay4
part4 = part4 & "</table>"
part4 = part4 & "</td>"
part4 = part4 & "<td valign='top' width='25%'>"
part4 = part4 & "<table width='100%' border='0' cellspacing='5' cellpadding='0'>"
part4 = part4 & F_Protected_Veteran_Status4
part4 = part4 & F_Disability4
part4 = part4 & F_Retaliation4
part4 = part4 & "</table>"
part4 = part4 & "</td>"
part4 = part4 & "</tr>"
part4 = part4 & "</table>"
part4 = part4 & "</td>"
part4 = part4 & "</tr>"
part5 = ""
part5 = part5 & "<!------------------------"
part5 = part5 & "SECTION 5"
part5 = part5 & "------------------------->"
part5 = part5 & "<tr>"
part5 = part5 & "<td align=center><b>How did you learn that<br> you could file a <br>complaint with OFCCP?</b></td>"
part5 = part5 & "<td >"
part5 = part5 & "<table border='0' cellspacing='0' cellpadding='5'>"
part5 = part5 & F_Complaint5
part5 = part5 & "</table>"
part5 = part5 & "</td>"
part5 = part5 & "</tr>"
part6 = ""
F_Narrative5 = Replace(F_Narrative5, nlcr, "<br><br>")
part6 = part6 & "<!------------------------"
part6 = part6 & "SECTION 6"
part6 = part6 & "------------------------->"
part6 = part6 & "<tr>"
part6 = part6 & "<td align=center><b>Your Complaint:</b></td>"
part6 = part6 & "<td>"
part6 = part6 & "<table border='0' cellspacing='0' cellpadding='5'>"
part6 = part6 & "<tr><td>Description:</td></tr>"
part6 = part6 & "<tr><td>" & F_Narrative5 & "</td></tr>"
part6 = part6 & "</table>"
part6 = part6 & "</td>"
part6 = part6 & "</tr>"
F_Narrative6 = Replace(F_Narrative6, nlcr, "<br><br>")
part7 = ""
part7 = part7 & "<!------------------------"
part7 = part7 & "SECTION 7"
part7 = part7 & "------------------------->"
part7 = part7 & "<tr>"
part7 = part7 & "<td align=center><b>Do you think the <br>discrimination includes or <br>affects others?</b></td>"
part7 = part7 & "<td >"
part7 = part7 & "<table border='0' cellspacing='0' cellpadding='5'>"
part7 = part7 & "<tr><td>Do you believe other employees or applicants were treated the same way as you described above?:<u>" & String(10,vspc) & F_Treated5 & String(10,vspc) & "</u></td></tr>"
part7 = part7 & "<tr><td>" & F_Narrative6 & "</td></tr>"
part7 = part7 & "</table>"
part7 = part7 & "</td>"
part7 = part7 & "</tr>"
part8 = ""
part8 = part8 & "<!------------------------"
part8 = part8 & "SECTION 8"
part8 = part8 & "------------------------->"
part8 = part8 & "<tr>"
part8 = part8 & "<td align=center><b>Do you have an <br>attorney or other<br> representative?</b></td>"
part8 = part8 & "<td >"
part8 = part8 & "<table border='0' cellspacing='0' cellpadding='5'>"
part8 = part8 & "<tr><td>If you are represented by an attorney, or another person, or an organization, please provide their contact information below." & "</td></tr>"
part8 = part8 & "<tr><td>Name (First, Middle, Last):<input size= '50' type='text' name='name' readonly value='" & F_Fullname21 & "'><br></td></tr>"
part8 = part8 & "<tr><td>Street Address:<input size= '50' type='text' name='address' readonly value='" & F_Address21 & "'><br></td></tr>"
part8 = part8 & "<tr><td>City:<input size= '30' type='text' name='city' readonly value='" & F_City21 & "'>"
part8 = part8 & "State:<input size= '3' type='text' name='state' readonly value='" & F_state21 & "'>"
part8 = part8 & "Zip Code:<input size= '10' type='text' name='zip' readonly value='" & F_Zipcode21 & "'></td></tr>"
part8 = part8 & "<tr><td>Telephone Number:" & F_Telephone21 & "</td></tr>"
part8 = part8 & "<tr><td>E-mail:<input size= '30' type='text' name='email' readonly value='" & F_Email21 & "'></td></tr>"
part8 = part8 & "<tr><td>Who should we contact if we need more information about your description of what occurred?<br>" & F_Attorney5 & "</td></tr>"
part8 = part8 & "</table>"
part8 = part8 & "</td>"
part8 = part8 & "</tr>"
part9 = ""
part9 = part9 & "<!------------------------"
part9 = part9 & "SECTION 9"
part9 = part9 & "------------------------->"
part9 = part9 & "<tr>"
part9 = part9 & "<td align=center><b>Signature and Verification</b></td>"
part9 = part9 & "<td >"
part9 = part9 & "<table border='0' cellspacing='0' cellpadding='5'>"
part9 = part9 & "<tr><td>I declare under penalty of perjury that the information given above is true and correct to the best of my knowledge or belief. A willful false statement is punishable by law.<br><br>I hereby authorize the release of any medical information needed for this investigation." & "</td></tr>"
part9 = part9 & "<tr><td>Signature of Complainant:"
part9 = part9 & "<input size= '30' type='text' name='Signature' readonly value='"
part9 = part9 & F_Print_Signature
part9 = part9 & "'>"
part9 = part9 & "Date:"
part9 = part9 & "<input size= '10' type='text' name='Signature_Date' readonly value='"
part9 = part9 & F_Print_Signature_Date
part9 = part9 & "'>"
part9 = part9 & "</td></tr>"
part9 = part9 & "</table>"
part9 = part9 & "</td>"
part9 = part9 & "</tr>"
'part1 = ""
'part2 = ""
'part3 = ""
'part4 = ""
'part5 = ""
'part6 = ""
'part7 = ""
'part8 = ""
'part9 = ""
htmltail = "</table></body></html>"
'----------------------------------------
' Send email to a specific region based on State
'----------------------------------------
Select Case F_state1
'---------------------------------------------
'These states are assigned to Region [email protected]
'New Jersey, New York, Puerto Rico,Virgin Islands, Connecticut, Maine, Massachusetts,
'New Hampshire, Rhode Island or Vermont
'---------------------------------------------
case "NJ" , "NY" , "PR" , "VI" , "CT" , "ME" , "MA" , "NH" , "RI" , "VT"
region = 1
region_title = ""
region_email = "[email protected]"
'---------------------------------------------
'These states are assigned to Region [email protected]
'Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia
'---------------------------------------------
case "DE" , "DC" , "MD" , "PA" , "VA" , "WV"
region = 2
region_title = ""
region_email = "[email protected]"
'---------------------------------------------
'These states are assigned to Region [email protected]
'Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee
'---------------------------------------------
case "AL" , "FL" , "GA" , "KY" , "MS" , "NC" , "SC" , "TN"
region = 3
region_title = ""
region_email = "[email protected]"
'---------------------------------------------
'These states are assigned to Region [email protected]
'Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, Wisconsin
'---------------------------------------------
case "IL" , "IN" , "LA" , "KS" , "MI" , "MN" , "MO", "NE" , "OH" , "WI"
region = 4
region_title = ""
region_email = "[email protected]"
'---------------------------------------------
'These states are assigned to Region [email protected]
'Arkansas, Colorado, Louisiana, Montana, New Mexico, North Dakota, Oklahoma,
'South Dakota, Texas, Utah, Wyoming
'---------------------------------------------
case "AR" , "CO" , "MT" , "NM" , "ND" , "OK" , "SD", "TX" , "UT" , "WY"
region = 5
region_title = ""
region_email = "[email protected]"
'---------------------------------------------
'These states are assigned to Region [email protected]
'Alaska, Arizona, California, Guam, Hawaii, Idaho, Nevada, Oregon, Washington
'---------------------------------------------
case "AK" , "AZ" , "CA" , "GU" , "HI" , "ID" , "NV", "OR" , "WA"
region = 6
region_title = ""
region_email = "[email protected]"
End Select
html = ""
knt = 0
txt = ""
'----------------------------------------
' SEND TO REGION
'----------------------------------------
Set Mailer = Server.CreateObject("SMTPsvg.Mailer")
Mailer.FromName = "OFCCP - Department Of Labor"
Mailer.FromAddress= SENDER_EMAIL_ADDRESS
Mailer.RemoteHost = REMOTE_HOST_NAME
Mailer.AddRecipient region_email, SENDER_EMAIL_ADDRESS
'Mailer.AddRecipient region_email, region_email
Mailer.Subject = htmlsubject
Mailer.BodyText = htmlheader & part1 & part2 & part3 & part4 & part5 & part6 & part7 & part8 & part9 & htmltail
Mailer.ContentType = "text/html"
if Mailer.SendMail then
'Response.Write "Mail sent...<br><br>"
else
'Response.Write "Mail send failure. Error was " & Mailer.Response
end if
'----------------------------------------
' SEND TO COMPLAINANT
'----------------------------------------
Set Mailer = Server.CreateObject("SMTPsvg.Mailer")
Mailer.FromName = "OFCCP - Department Of Labor"
Mailer.FromAddress= SENDER_EMAIL_ADDRESS
Mailer.RemoteHost = REMOTE_HOST_NAME
Mailer.AddRecipient F_Fullname1, F_Email1
Mailer.Subject = htmlsubject
Mailer.BodyText = htmlheader & part1 & part2 & part3 & part4 & part5 & part6 & part7 & part8 & part9 & htmltail
Mailer.ContentType = "text/html"
if Mailer.SendMail then
'Response.Write "Mail sent...<br><br>"
else
'Response.Write "Mail send failure. Error was " & Mailer.Response
end if
'----------------------------------------
' Send thankyou to complainant
'----------------------------------------
Select Case F_Form_Language
case "English"
response.redirect "English_OFCCP_thankyou.html"
case "Spanish"
response.redirect "Spanish_OFCCP_thankyou.html"
case "Creole"
response.redirect "Creole_OFCCP_thankyou.html"
case "Vietnamese"
response.redirect "Vietnamese_OFCCP_thankyou.html"
case "Hmong"
response.redirect "Hmong_OFCCP_thankyou.html"
case "ChineseT"
response.redirect "Chinese_Traditional_OFCCP_thankyou.html"
case "ChineseS"
response.redirect "Chinese_Simplified_OFCCP_thankyou.html"
End Select
else
Response.Write "<p>Please click Back-Space on your browser and review each entry:</p>"
Response.Write "COMPLAINT FORM ERROR<br>--------------------------<br><br>" & etxt
End if
%>