<% 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 = "j.milde@mra-sf.com" objCDO.To = "j.milde@mra-sf.com,knightortho@insightbb.com" objCDO.Subject = "FormMail from " & Request.ServerVariables("URL") objCDO.TextBody = "FormMail from " & Request.ServerVariables("URL") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "FullName: " objCDO.TextBody = objCDO.TextBody & Request("FullName") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Address: " objCDO.TextBody = objCDO.TextBody & Request("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 & "PostalCode: " objCDO.TextBody = objCDO.TextBody & Request("PostalCode") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Country: " objCDO.TextBody = objCDO.TextBody & Request("Country") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Telephone: " objCDO.TextBody = objCDO.TextBody & Request("Telephone") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Email: " objCDO.TextBody = objCDO.TextBody & Request("Email") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Alternate Email: " objCDO.TextBody = objCDO.TextBody & Request("ALT_Email") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Amount_of_Time: " objCDO.TextBody = objCDO.TextBody & Request("Amount_of_Time") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Preferred_Language: " objCDO.TextBody = objCDO.TextBody & Request("Preferred_Language") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "English: " objCDO.TextBody = objCDO.TextBody & Request("English") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Poster_or_case: " objCDO.TextBody = objCDO.TextBody & Request("Poster_or_case") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Title: " objCDO.TextBody = objCDO.TextBody & Request("Title") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Abstract: " objCDO.TextBody = objCDO.TextBody & Request("Abstract") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Degrees_Education: " objCDO.TextBody = objCDO.TextBody & Request("Degrees_Education") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Society_Memberships: " objCDO.TextBody = objCDO.TextBody & Request("Society_Memberships") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Teaching_Appointments: " objCDO.TextBody = objCDO.TextBody & Request("Teaching_Appointments") 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.Write "

" Response.Write "Your application has been sent. Thank you!

" Response.Write "Return to the RWISO Home Page" Response.Write "
" Response.End end if %> RWISO Conferences - Speaker Application Information
Roth / Williams Made Our Smile
Roth / Williams International Society of Orthodontists Roth / Williams International Society of Orthodontists Roth / Williams International Society of Orthodontists Roth / Williams International Society of Orthodontists

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SPEAKER APPLICATION FORM

Apply to Speak at the 2011 Meeting

" name="appform">
Speaker Information
Full Name
Address
City
State/Province
Postal Code
Country
Telephone Number
E-mail Address
Alternate E-mail Address
Presentation Information
Amount of Time Requested
Preferred language
Are you able to present in English Yes
No
Will you consider presenting a Poster or Case Display Yes
No
Title of Presentation
(Limit up to 20 words)
Abstract of Presentation
(Limit up to 100 words)
Biographical Data
Degrees Earned / Educational Background
Society Memberships
(Please do not use abbreviations/acronyms)
Teaching Appointments
By submitting this form, I authorize the Roth/Williams International Society of Orthodontists to tape, reproduce, and distribute in audio and/or video form my presentation at the 18th Annual Meeting of RWISO (2011).

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