B Z Financial

<%@ Language= VBScript %> <% dim firstName dim lastName dim SpouseFirstName dim spouseLastName dim HomePhone dim workPhone dim mobilePhone dim address dim city dim state dim zipcode dim email dim emergencysavings dim retirementsavings dim financialGoal1 dim financialGoal2 dim financialGoal3 dim debtTypes dim otherDebtType dim totalDebt dim totalCreditCards dim totalCreditUsed dim comments firstName = request.form("FirstName") lastName = request.form("LastName") SpouseFirstName = request.form("SpouseFirstName") spouseLastName = request.form("SpouseLastName") HomePhone = request.form("HomePhone") workPhone = request.form("WorkPhone") mobilePhone = request.form("MobilePhone") address = request.form("Address") city = request.form("City") state = request.form("State") zipcode = request.form("ZipCode") email = request.form("Email") emergencysavings = request.form("EmergencySavings") retirementsavings = request.form("RetirementSavings") financialGoal1 = request.form("FinancialGoal1") financialGoal2 = request.form("FinancialGoal2") financialGoal3 = request.form("FinancialGoal3") debtTypes = request.form("Debts") otherDebtType = request.form("OtherDescribe") totalDebt = request.form("TotalDebt") totalCreditCards = request.form("TotalCreditCards") totalCreditUsed = request.form("CreditUsed") comments = request.form("Comments") if firstName = "" then %>

Online Financial Worksheet

Fill in the following information and click submit. Once received, one of our consultants will contact you to set up an appointment for your consultation.

First Name
Last Name
Spouse/Partner First Name
Spouse/Partner Last Name
Home Phone
Work Phone
Mobile Phone
Address
City
State
Zip Code
Email
Emergency Savings
Retirement Savings
Top 3 Financial Goals
1
2
3
A bit about your debt situation
What type of debts do you have now?	Check all that apply
	Mortgage2nd Mortgage
	Auto Loan(s)RV Loan(s)
	Major Credit cards (Visa, MC, AMEX, Discover)
	Store Cards Medical Bills
	CollectionsCharge-Offs
	Other:
Estimate Total Debt
Total On Major Credit Cards
Estimate of total credit used	0-25%25-50%50-75%75% or more At or over limit
Comments/Questions

<% else Dim DB_CONNECTIONSTRING DB_CONNECTIONSTRING = "DRIVER={MySQL ODBC 3.51 Driver}; SERVER=p41mysql29.secureserver.net; PORT=3306; DATABASE=bzfinancial; USER=bzfinancial; PASSWORD='wsop2007Winner'; OPTION=0;" dim objRecordset set objRecordset = Server.CreateObject("ADODB.Recordset") objRecordset.open "bzfinancial.FinancialWorksheets",DB_CONNECTIONSTRING,0,2 objRecordset.addnew objRecordset.Fields("FirstName") = firstName objRecordset.Fields("LastName") = lastName objRecordset.fields("SpouseFirstName") = spouseFirstName objRecordset.fields("SpouseLastName") = spouseLastName objRecordset.fields("HomePhone") = homephone objRecordset.fields("WorkPhone") = workphone objRecordset.fields("MobilePhone") = mobilePhone objRecordset.fields("Address") = address objRecordset.fields("City") = city objRecordset.fields("State") = state objRecordset.fields("ZipCode") = zipcode objRecordset.fields("Email") = email objRecordset.fields("EmergencySavings") = emergencySavings objRecordset.fields("RetirementSavings") = retirmentSavings objRecordset.fields("FinancialGoal1") = financialGoal1 objRecordset.fields("FinancialGoal2") = financialGoal2 objRecordset.fields("FinancialGoal3") = financialGoal3 objRecordset.fields("DebtTypes") = debttypes objRecordset.fields("OtherDebtType") = otherDebtType objRecordset.fields("TotalDebt") = totalDebt objRecordset.fields("TotalCreditCards") = totalCreditCards objRecordset.fields("TotalCreditUsed") = totalCreditUsed objRecordset.fields("Comments") = comments objRecordset.update objRecordset.Close set objRecordset = nothing set objConnection = nothing dim objCDOMail set objCDOMail = server.createobject("CDONTS.NewMail") objCDOMail.From = "BZ Financial Confirmation Form " objCDOMAil.To = "consultations@bzfinancial.com" objCDOMail.Subject = "New Lead waiting" objCDOMail.Body = firstName & " " & lastName & " just submitted their info." objCDOMail.send set objCDOMail = nothing %>

Thank you for your submission

One of our consultants will contact you as soon as possible to arrange your consultation appointment.

<% end if %>

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