<% if Request("submit") <> "" then Dim objCDO Set objCDO = Server.CreateObject("CDO.Message") Dim objCDOConf Set objCDOConf = Server.CreateObject("CDO.Configuration") With objCDOConf.Fields .Item(cdoSendUsingMethod) = 2 .Item(cdoSMTPServer) = "mail-fwd" .Item(cdoSMTPServerPort) = 25 .Item(cdoSMTPconnectiontimeout) = 10 .Update End With Set objCDO.Configuration = objCDOConf ' Be sure to use a valid email addresses below: objCDO.From = "memberservices@nyssohns.org" objCDO.To = "memberservices@nyssohns.org" objCDO.Subject = "NYSSO-HNS Web Site Registration Form from " & Request.ServerVariables("URL") objCDO.TextBody = "Registration Information from " & Request.ServerVariables("URL") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Physician First Name: " objCDO.TextBody = objCDO.TextBody & Request("Physician First Name") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Physician Last Name: " objCDO.TextBody = objCDO.TextBody & Request("Physician Last Name") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Street Address: " objCDO.TextBody = objCDO.TextBody & Request("Street Address") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "City: " objCDO.TextBody = objCDO.TextBody & Request("City") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "State: " objCDO.TextBody = objCDO.TextBody & Request("State") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Zip Code: " objCDO.TextBody = objCDO.TextBody & Request("Zip Code") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Phone : " objCDO.TextBody = objCDO.TextBody & Request("Phone ") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Physician E-mail: " objCDO.TextBody = objCDO.TextBody & Request("Physician E-mail") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Set a User ID: " objCDO.TextBody = objCDO.TextBody & Request("Set a User ID") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Set a Password: " objCDO.TextBody = objCDO.TextBody & Request("Set a Password") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.Send 'Clean-up Set objCDO = Nothing Set objCDOConf = Nothing ' Happy response. If you would rather, ' change the following to ' Response.Redirect "thanks.html" or similar Response.Redirect "thankyoureg.html" Response.End end if %> Member Web Site Registration

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Complete the information requested below and click Submit.

PLEASE NOTE, REGISTRATION IS NOT INSTANTANEOUS!

We must verify your membership and activate the User ID and Password you give us here.

The system is updated at 12:00 pm and 3:00 pm daily so please try back later.



Physician First Name
Physician Last Name
Street Address
City
State
Zip
Phone
Physician E-mail
Set a User ID
Set a Password