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<title>Pianificazione fondi d'investimento</title>
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<td align="left" valign="top" width="490"><span class="section">SPECIALE
</span><span class="title">
Cassa Malati - Maggiori informazioni
</span>
Per maggiori informazioni compilate il seguente formulario.
Tutti i campi indicati con (*) sono obbligatori e ci serviranno ad ottenere un quadro economico più esaustivo.
Verrete ricontattati al più presto.
<?
$errori=false;
//if (!(isset($HTTP_POST_VARS["step"]))) {
?>
<FORM NAME="sponsor" ACTION="prodotti/privati/prestiti_form.php" METHOD="POST">
<INPUT TYPE="hidden" NAME="step" VALUE="invia"><INPUT TYPE="hidden" NAME="mail" VALUE="info@daxa.ch">
Nome (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="Nome" size="24">
Cognome (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="Cognome" size="24">
Indirizzo (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="Via" value="Via" size="32">
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="cp" value="cp" size="5" maxlength="5"> - <input type="text" name="Citta" value="Città" size="24">
<table border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="250">
Data di nascita (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
</td>
<td>
Sesso (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
</td>
</tr>
<tr>
<td width="250">
<table border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="52"><select name="gg" size="1">
<option selected value="gg">gg</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select></td>
<td width="92"><select name="mm" size="1">
<option selected value="mm">mm</option>
<option value="gennaio">Gennaio</option>
<option value="febbraio">Febbraio</option>
<option value="marzo">Marzo</option>
<option value="aprile">Aprile</option>
<option value="maggio">Maggio</option>
<option value="giugno">Giugno</option>
<option value="luglio">Luglio</option>
<option value="agosto">Agosto</option>
<option value="settembre">Settembre</option>
<option value="ottobre">Ottobre</option>
<option value="novembre">Novembre</option>
<option value="dicembre">Dicembre</option>
</select></td>
<td><select name="aa" size="1">
<option selected value="aa">aa</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
</select></td>
</tr>
</table>
</td>
<td>
<table border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="45"><input type="radio" name="Sesso" value="M"> M</td>
<td><input type="radio" name="Sesso" value="F"> F</td>
</tr>
</table>
</td>
</tr>
</table>
Somma richiesta (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="Somma" size="24"> Chf
<table border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="250">
Rata massimale (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
</td>
<td>
N. Rate (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
</td>
</tr>
<tr>
<td width="250"><input type="text" name="Massimale" size="24"> Chf</td>
<td><select name="Rate" size="1">
<option value="null">--</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
</select></td>
</tr>
</table>
Telefono abitazione (*)
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="tel_casa" size="14" maxlength="14">
Telefono ufficio
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="tel_ufficio" size="14" maxlength="14">
Cellulare
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="cell" size="14" maxlength="14">
Orario di reperibilità
<table width="1" border="0" cellspacing="0" cellpadding="0" height="3">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
<input type="text" name="ora" size="5" maxlength="5">
<table border="0" cellspacing="0" cellpadding="0">
<tr>
<td><input type="image" src="media/invia.gif"></td>
<td width="10"></td>
<td>[img]media/reset.gif[/img]</td>
</tr>
</table>
<span class="blu">></span>
<span class="black">Torna alla sezione</span>
<table width="1" border="0" cellspacing="0" cellpadding="0" height="16">
<tr>
<td><spacer height="1" type="block" width="1"></td>
</tr>
</table>
</FORM>
<? if (!(isset($HTTP_POST_VARS["step"]))) {
}else{//step
if ($HTTP_POST_VARS["step"]=='invia') {
if ((($HTTP_POST_VARS["Nome"])=="") or (($HTTP_POST_VARS["Cognome"])=="") or (($HTTP_POST_VARS["Via"])=="") or (($HTTP_POST_VARS["cp"])=="") or (($HTTP_POST_VARS["Citta"])=="") or (($HTTP_POST_VARS["gg"])=="gg") or (($HTTP_POST_VARS["mm"])=="mm") or (($HTTP_POST_VARS["aa"])=="aa") or (($HTTP_POST_VARS["Sesso"])=="null") or (($HTTP_POST_VARS["Massimale"])=="") or (($HTTP_POST_VARS["Rate"])=="null") or (($HTTP_POST_VARS["tel_casa"])=="")) {
//ViewErrore("Non sono stati compilati tutti i campi");
//header($percorsoweb.'info_no.html',false);
?>
<SCRIPT TYPE="text/javascript">
searchWin = window.open("info_no.html",'finestra','scrollbars= no,resizable=no,width=450,height=350,status=no,loc ation=no,toolbar=no,left=100,top=200');
</SCRIPT>
<? }else{
//SPEDISCO EMAIL
//header($percorsoweb.'info_ok.html');
$to = "\"Daxa Assicurazioni - Support Center\" <info@brainprogress.com>";
$subject = "Daxa.ch: Richiesta offerta prestito";
$testo_mail = "Dati compilati sul sito:
Nome: ".$HTTP_POST_VARS["Nome"]."
Cognome: ".$HTTP_POST_VARS["Cognome"]."
Via / Piazza: ".$HTTP_POST_VARS["Via"]."
Cod. Postale: ".$HTTP_POST_VARS["cp"]."
Località: ".$HTTP_POST_VARS["Citta"]."
Data di nascita: ".$HTTP_POST_VARS["gg"]." + " / " + ".$HTTP_POST_VARS["mm"]." + " / " ".$HTTP_POST_VARS["aa"]."
Sesso: ".$HTTP_POST_VARS["Sesso"]."
Somma richiesta: ".$HTTP_POST_VARS["Somma"]."
Rata massimale: ".$HTTP_POST_VARS["Massimale"]."
N. Rate: ".$HTTP_POST_VARS["Rate"]."
Telefono casa: ".$HTTP_POST_VARS["tel_casa"]."
Telefono ufficio: ".$HTTP_POST_VARS["tel_ufficio"]."
Telefono cellulare: ".$HTTP_POST_VARS["cell"]."
Daxa.ch - Support Center";
$from = $HTTP_POST_VARS["mail"];
$send=mail($to,$subject,$testo_mail,"From: ".$from);
?>
<SCRIPT TYPE="text/javascript">
searchWin = window.open("info_ok.html",'finestra','scrollbars= no,resizable=no,width=450,height=350,status=no,loc ation=no,toolbar=no,left=100,top=200');
</SCRIPT>
<? }//campi
}//step invia
}//step vuoto
?>
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