Signup for our services

Enter your name *
Organization name
Contact phone *
eMail ID
No. of physicians in the group
Specialty
Location
Current cost per line
Specific requirements
Type of Services

<% if request.servervariables("Request_method") = "POST" then dim oSMTP On Error Resume Next Set oSMTP = Server.CreateObject("SMTPControl.SMTP") oSMTP.Server = "210.18.115.20" '"210.18.115.20" '"172.16.0.198" ' oSMTP.MailFrom ="customer@rndsoftech.com" oSMTP.SendTo = "Rajesh@rndsoftech.com" '"Rajesh@rndsoftech.com" '"gopinathan@rndmail.com" ' oSMTP.MessageSubject = "New customer enquiry" oSMTP.MessageText = "Name: " & request.form("name") & vbcrlf & "Organization name: " & request.form("orgname") & vbcrlf & "Contact phone: " & request.form("phone") & vbcrlf & "eMail id: " & request.form("mail") & vbcrlf & "No of doctors in practice: " & request.form("doc") & vbcrlf & "Speciality: " & request.form("speciality") & vbcrlf & "Location: " & request.form("location") & vbcrlf & "Current cost per line: " & request.form("cost") & vbcrlf & "Specific requirements : " & request.form("questions") & vbcrlf & "Type of services : " & request.form("services") & vbcrlf & vbcrlf & "This is an automated message. customer@rndsoftech.com does not exist. Pls do not reply to this mail" oSMTP.SendEmail Dim ErrMsg ErrMsg = Err.number & "\" & Err.Description If Err.Number <> 0 Then Response.Write "Error " & Err.Number & ": " & Err.Description Else Response.Write "" End If end if %>