<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<title>
Chakmak
</title>
<link rel="stylesheet" media="screen" type="text/css" href="script/control.css"/>
<link href="subscription/chakmak.css" rel="stylesheet" type="text/css" />
<script type="text/javascript" src="subscription/chakmak.js"></script>
<script src="https://www.google.com/recaptcha/api.js" async defer></script>
<script type="text/javascript">
<?php
include "define.php";
global $subscrPay;
$js_array = json_encode($subscrPay);
echo "var payArr = " .$js_array . ";\n";
?>
function displayPayment(id, from)
{
var type = '';
var subscr = '';
if(from == 's')
{
var type = document.getElementById("member").value;
subscr = id;
}
else if(from == 't')
{
var subscr = document.getElementById("scheme").value;
type = id;
}
document.getElementById("subpay").innerHTML = payArr[type][subscr];
}
</script>
</head>
<?php
global $subscrType;
global $subscrScheme;
?>
<body>
<div id="container">
<div id="social">
<table cellspacing="3 px" cellpadding="0">
<tr>
<td><p>Follow us on: </p></td>
<td><a href="http://chakmak-blog.blogspot.com" target="_blank"><img src="images/blogger.png"/></a></td>
<td><a href="http://twitter.com/chakmakmag" target="blank"><img src="images/twitter.png" /></a></td>
<td><a href="http://www.facebook.com/pages/Chakmak/119248164817634" target="_blank"><img src="images/facebook.png" /></a></td>
</tr>
</table>
</div>
<div id="header">
<a href="http://www.eklavya.in/chakmak/chakmak/"><img src="images/header.png" /></a>
</div>
<table id="nav">
<tr>
<td align="left" width="370 px"><a href="http://www.eklavya.in">Eklavya.in</a></td>
<td width="80 px" align="center"><a href="http://chakmak.eklavya.in">Home</a></td>
<td width="90 px" align="center"><a href="event.html">300th Issue</a></td>
<td width="80 px" align="center"><a href="http://www.eklavya.in/magazine-activity/chakmak-magazine">Archive</a></td>
<td width="80 px" align="center"><a href="sadasyata.php">Subscribe</a></td>
<td width="80 px" align="center"><a href="contribution.html">Contribute</a></td>
<td width="80 px" align="center"><a href="http://chakmak-blog.blogspot.com">Blog</a></td>
<td width="80 px" align="center"><a href="event.html">Contact us</a></td>
</tr>
</table>
<!--change the value of iframe src according to the month-->
<table width="100%">
<?php
if(isset($_GET['Message'])){
echo "Please Enter captcha properly";
}
?>
<tr style="float:left;"> <td>
<h2>Subscription Form</h2>
<p>Please fill this form, our representative will get back to you within 24 business hours.</p>
<div class="sr-sign-up-bg" id="main-change">
<form action="subscribe_process.php" name="" method="post">
<table cellspacing="10" cellpadding="3" align="left">
<tr>
<td ><input type="text" id="f_name" name="f_name" onBlur="if (this.value == '') {this.value = 'First Name:';}" onFocus="if (this.value == 'First Name:') {this.value = '';}" value="First Name:"/></td>
</tr>
<tr>
<td ><input type="text" id="l_name" name="l_name" onBlur="if (this.value == '') {this.value = 'Last Name:';}" onFocus="if (this.value == 'Last Name:') {this.value = '';}" value="Last Name:"/></td>
</tr>
<tr>
<td width="50px" >
<select id="member" name="member" onchange="displayPayment(this.value, 't');">
<option value="none">Please Select Chakmak Subscription Type</option>
<?php
foreach($subscrType as $k => $v)
{
echo '<option value="'.$k.'">'.$v.'</option>';
}
?>
</select>
</td>
</tr>
<tr>
<td width="50px" >
<select id="scheme" name="scheme" onchange="displayPayment(this.value, 's');">
<option value="none">Please Select Subscription Scheme</option>
<?php
foreach($subscrScheme as $k => $v)
{
echo '<option value="'.$k.'">'.$v.'</option>';
}
?>
</select>
</td>
</tr>
<tr>
<td>
<img src="images/rupee.gif" />
<label id="subpay">Select subscription</label>
</td>
</tr>
<tr>
<td width="50px" >
<select id="referral" name="referral">
<option value="none">Where did you hear about Chakmak?</option>
<option value="Facebook">From Chakmak FaceBook page</option>
<option value="Chakmak Blog">From Chakmak Blog</option>
<option value="Google Search">Found Chakmak on Google Search</option>
<option value="Reffered by Friend">A friend told me about Chakmak</option>
</select>
</td>
</tr>
<tr>
<td ><input type="text" id="add" name="add" value="Address:" onBlur="if (this.value == '') {this.value = 'Address:';}" onFocus="if (this.value == 'Address:') {this.value = '';}" /></td>
</tr>
<tr>
<td ><input type="text" id="city" name="city" onBlur="if (this.value == '') {this.value = 'City:'}" onFocus="if (this.value == 'City:') {this.value = '';}" value="City:"/></td>
</tr>
<tr>
<td ><input type="text" id="pcode" name="pcode" value="Pin Code:" onBlur="if (this.value == '') {this.value = 'Pin Code:'}" onFocus="if (this.value == 'Pin Code:') {this.value = '';}"/></td>
</tr>
<!--<tr>
<td ><input type="text" id="state" name="state" value="State/Region:" onBlur="if (this.value == '') {this.value = 'State/Region:'}" onFocus="if (this.value == 'State/Region:') {this.value = ''}"/></td>
</tr>-->
<tr>
<td >
<select name="state" id="state">
<option value="">State/Region:</option>
<option value="1">Andaman Nicobar </option>
<option value="2">Andhra Pradesh </option>
<option value="3">Arunachal Pradesh</option>
<option value="4">Assam </option>
<option value="5">Bihar </option>
<option value="6">Chandigarh </option>
<option value="7">Chattisgarh </option>
<option value="8">Dadra and Nagar Haveli </option>
<option value="9">Daman and Diu </option>
<option value="10">Delhi</option>
<option value="11">Goa </option>
<option value="12">Gujarat </option>
<option value="13">Haryana</option>
<option value="14">Himachal Pradesh</option>
<option value="15">Jammu and Kashmir </option>
<option value="16">Jharkhand </option>
<option value="17">Karnataka </option>
<option value="18">Kerala </option>
<option value="19">Madhya Pradesh </option>
<option value="20">Maharashtra </option>
<option value="21">Manipur</option>
<option value="22">Meghalaya </option>
<option value="23">Mizoram </option>
<option value="24">Nagaland </option>
<option value="25">Orissa </option>
<option value="26">Pondichery </option>
<option value="27">Punjab </option>
<option value="28">Rajasthan </option>
<option value="29">Sikkim </option>
<option value="30">Tamil Nadu </option>
<option value="31">Tripura </option>
<option value="32">Uttar Pradesh</option>
<option value="33">Uttaranchal </option>
<option value="34">West Bengal </option>
</select>
</td>
</tr>
<tr>
<td ><input type="text" id="email" name="email" value="Email:" onBlur="if (this.value == '') {this.value = 'Email:'}" onFocus="if (this.value == 'Email:') {this.value = ''}"/></td>
</tr>
<tr>
<td >
<input type="text" style="width:100px; vertical-align:super;" id="p_std_number" name="p_std_number" value="STD Code:" onBlur="if (this.value == '') {this.value = 'STD Code:'}" onFocus="if (this.value == 'STD Code:') {this.value = ''}" maxlength="5"/>
<label style="vertical-align:super;">-</label>
<input type="text" style="width:200px; vertical-align:text-bottom;" id="p_number" name="p_number" value="Phone Number:" onBlur="if (this.value == '') {this.value = 'Phone Number:'}" onFocus="if (this.value == 'Phone Number:') {this.value = ''}" maxlength="8"/>
</td>
</tr>
<tr>
<td ><input type="text" id="mobile" name="mobile" value="Mobile Number:" maxlength="10" onBlur="if (this.value == '') {this.value = 'Mobile Number:'}" onFocus="if (this.value == 'Mobile Number:') {this.value = ''}"/></td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<label for="chakmak_issue" title="Chakmak's 300th Issue" style="vertical-align:super;">
I would also like to purchase Chakmak's 300th issue:
</label>
</td>
<td style="width:30px;">
<input id="chakmak_issue" type="checkbox" style="width:40px;" value="1" style="vertical-align:text-bottom;" title="Chakmak's 300th Issue" name="chakmak_issue" />
</td>
<td rowspan="2"><img src="images/ThreeHundred.png" title="Chakmak's 300th Issue" alt="Chakmak's 300th Issue" /></td>
</tr>
<tr>
<td colspan="2">
<label>( <img src="images/rupee.gif" /> 150 /- )</label>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td >
<label>Special Instructions: </label>
<textarea style="margin-top:5px;" id="instruction" name="instruction" rows="3" cols="70" ></textarea>
</td>
</tr>
<tr>
<td >
<label>Captcha: </label>
<div class="g-recaptcha" data-sitekey="6LdoYSgTAAAAACKSTMuekMDWv6dXXOrble62Gedw" ></div>
</td>
</tr>
<tr>
<td><!--input type="image" class="submit-btn" name="submit" value="Submit" src="subscription/submit-btn.png" onClick="return Validation_form()"/-->
<input type="submit" value="Submit For Online Payment" style="cursor:pointer;background:#00CCFF;width:220px;" name="order_is_payment_online[]" onClick="return Validation_form()"/>
<!-- <input type="submit" value="Submit For Offline Payment" style="cursor:pointer;background:#00CCFF;width:220px;" name="order_is_payment_online[]" onClick="return Validation_form()" /> --->
</td>
</tr>
</table>
</form>
</div>
</tr>
<tr style="float:right"> <td> <div id="sidebar" align="right">
<table>
<tr>
<td><a href="sadasyata.php"><img src="images/rate.png" border="1px" /></a></a></td>
</tr>
<tr>
<td><br/>
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<div class="fb-like-box" data-href="http://www.facebook.com/chakmak.magazine" data-width="200" data-show-faces="true" data-stream="true" data-header="true"></div>
</td>
</tr>
</table>
</div>
</td></tr>
</table>
<div id="footer">
<img src="images/footer.jpg"/>
<hr width="100%" color="#33cc33">
<table width="100%">
<tr>
<td align="left">© Copyrights reserved by Eklavya Foundation</td>
</tr>
</table>
</div>
</div>
</body>
</html>