Webshop sign-up Form

Thank you for your interest in WebShop, the Parts Plus portal to Parts, Information and more. To place a request for a username and login, please fill out this form completely.

*Indicates a required field.

Your Information   The Parts Plus Supplier you wish to access:
Name:

*

 

Business Name:

*

Phone:

*   Street Address:
Fax:   City:
*

Email:

*   State: *

Business Name:

*   Zip:

Business Address:

*  

Phone:

*

City:

*  

Fax:

State:

*   Contact Name:
Zip: *      
Type of Business:
Repair Facility
Parts Store
Fleet
Government Agency
Other
     
Enter the encryption code to submit contact form

 

 
TERMS OF USE: This site is the property of the Automotive Distribution Network. Parts Plus WebShop is restricted to authorized users only, and with your logon to Parts Plus WebShop you are consenting to monitoring of your usage of the site. Copyright ©2008 Automotive Distribution Network. All rights reserved.
"; //echo("$user"); if($user!=$key || ereg("^[ \t\r\n]$",$imag) ) { //echo "You have entered wrong verification code!!
Please go back and enter proper value."; $error = "Invalid verification code"; header("Location: http://www.partsplusportal.com/signup.php?error=$error"); exit(); } $date = Date('m-d-Y'); $timestamp = `date`; $recipients = "webshop@networkhq.org"; $subject = "Parts Plus Webshop Portal Request"; $message = "Name: $name\n"; $message .= "Phone: $phone\n"; $message .= "Fax: $fax\n"; $message .= "Email: $email\n"; $message .= "Business Name: $business\n"; $message .= "Address: $address\n"; $message .= "City: $city\n"; $message .= "State: $state\n"; $message .= "Zip: $zip\n"; $message .= "Business Type: $type\n"; $message .= "- - - - - - -\n"; $message .= "Supplier Name: $b_name\n"; $message .= "Supplier Address: $b_address\n"; $message .= "City: $b_city\n"; $message .= "State: $b_state\n"; $message .= "Zip: $b_zip\n"; $message .= "Supplier Phone: $b_phone\n"; $message .= "Supplier Fax: $b_fax\n"; $message .= "Supplier Contact Name: $b_contact\n"; $sender = "Parts Plus Webshop Portal"; mail($recipients,$subject,$message,$sender); $line = "$name|$phone|$fax|$email|$business|$address|$city|$state|$zip|$type|$b_name|$b_address|$b_city|$b_state|$b_zip|$b_phone|$b_fax|$b_contact"; $fp = fopen("./data/webshop.txt","a"); fwrite ($fp,$line); fclose($fp); ?> The Network HQ