" size="35" maxlength="60"></td>
<td>Email*:</td>
<td><input name="email" type="text" id="email" value="<?php
echo $email;
?>
" size="35" maxlength="120"></td>
</tr>
<tr>
<td>City:</td>
<td><input name="city" type="text" id="city" value="<?php
echo $city;
?>
" maxlength="100"></td>
<td>State:</td>
<td><?php
echo showStateList($db, $state);
?>
</td>
</tr>
<tr>
<td>Company**:</td>
<td><input name="company" type="text" id="company" value="<?php
echo $company;
?>
" size="35" maxlength="120"></td>
<td>Phone***:</td>
<td><input name="phone" type="text" id="phone" value="<?php
echo $phone;
?>
" maxlength="16"></td>
</tr>
<tr>
<td class="tborderUL">State Codes From: </td>
<td class="tborderUR"><?php
echo showStateList($resdb, $state);
?>
</td>
<td class="tborderDL">OR:</td>
<td colspan="2" class="tborderDR"><?php
echo showSpecList($resdb, $spec3, 'spec3');
?>
</td>
</tr>
<tr>
<td class="tborderDL">State Codes To: </td>
<td class="tborderDR"><?php
echo showStateList($resdb, $state2, 'state2');
?>
</td>
<td><a href="editprog.php?y=2010" target="_blank">Res.Program</a>:</td>
<td colspan="2"><input name="program" type="text" id="program"></td>
</tr>
<tr>
<td>Modified from:</td>
<td title="Year 2000 means 'From the beginning'"><script language="javascript">DateInput('mofrom2', false, 'YYYY-MM-DD', '<?php
echo $mofrom2 ? $mofrom2 : '2000-01-01';
?>
');</script></td>
<td>To:</td>
<td title="Year 2000 means 'To the end',
and 2008-09-05 is day One"><script language="javascript">DateInput('moto2', false, 'YYYY-MM-DD', '<?php
echo $moto2 ? $moto2 : '2008-09-06';
?>
> Public Health</option>
<option value="Rural" <?php
echo $pref_practice == 'Rural' ? 'selected' : '';
?>
> Rural HC</option>
<option value="ER" <?php
echo $pref_practice == 'ER' ? 'selected' : '';
?>
> ER/Urgent</option>
</select></td>
</tr>
<tr>
<td>Preferred State:</td>
<td><?php
echo showStateList($resdb, $pref_states, 'pref_states');
?>
</td>
<td><label>
<input name="pref_stopen" type="checkbox" id="pref_stopen" value="1" <?php
echo $pref_stopen ? 'checked' : '';
?>
>
OPEN</label></td>
<td colspan="2" valign="middle">Pref. Region:
<select name="pref_region" id="pref_region">
<option value="0"> </option>
<?php
$sql = "select reg_id,reg_name from regions where reg_id != 0 order by reg_id";
$regs = $resdb->query($sql);
if ($regs) {
" maxlength="50"></td>
<td class="tborderUR">Zip:
<input name="zip" type="text" id="zip2" value="<?php
echo $zip;
?>
" size="12" maxlength="10"></td>
</tr>
<tr>
<td>Phone:</td>
<td><input name="phone" type="text" id="phone" value="<?php
echo $phone2;
?>
" maxlength="16"></td>
<td class="tborderDL">State:</td>
<td colspan="2" class="tborderDR"><?php
echo showStateList($resdb, $state);
?>
</td>
</tr>
<tr>
<td>Email: </td>
<td><input name="email" type="text" id="email" value="<?php
echo stripslashes($email);
?>
" maxlength="128"></td>
<td> </td>
<td colspan="2"> </td>
</tr>
<tr>
<td> </td>
<td><label>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td>Address:</td>
<td><input name="addr1" type="text" id="addr1" size="35" maxlength="100"></td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>City:</td>
<td><input name="city" type="text" id="city" maxlength="50"></td>
<td>State:</td>
<td><?php
echo showStateList($resdb);
?>
</td>
<td>Zip:</td>
<td><input name="zip" type="text" id="zip" size="15" maxlength="10"></td>
</tr>
<tr>
<td>Phone:</td>
<td><input name="phone" type="text" id="phone" maxlength="16" onChange="checkPhoEx(phone,'Phone',state,'State')"></td>
<td>Director:</td>
<td><input name="dir_name" type="text" id="dir_name" size="35" maxlength="50"></td>
<td> </td>
<td align="right"><input type="submit" name="submit" value="Submit"></td>
</tr>
</table>
</form></div>
}
?>
>Expired</option>
</select></td>
<td>Facility:</td><td><input name="o_facility" type="text" value="<?php
echo $opp->o_facility;
?>
" size="40" maxlength="100"></td>
</tr>
<tr>
<td>City:</td><td><input name="o_city" type="text" maxlength="50" value="<?php
echo $opp->o_city;
?>
"></td>
<td>State:</td><td><?php
echo showStateList($db, $opp->o_state, "o_state");
?>
<br>
<input name="show_state" type="checkbox" value="1" <?php
if ($opp->show_state) {
echo 'checked';
}
?>
> Show state to job seekers
</td>
</tr>
<tr><td>Zip:</td><td><input name="o_zip" type="text" maxlength="5" value="<?php
echo $opp->o_zip;
?>
"></td>
<td>Underserved area:</td>
" size="50" maxlength="100">
Line 2:
<input name="addr2" type="text" id="addr2" value="<?php
echo $doc->addr2;
?>
" size="45" maxlength="100"></td>
</tr>
<tr>
<td>City:</td>
<td><input name="city" type="text" id="city" value="<?php
echo $doc->city;
?>
" maxlength="30"></td>
<td>State:</td>
<td><?php
echo showStateList($ama, $doc->state);
?>
</td>
<td>Zip:</td>
<td><input name="zip" type="text" id="zip" value="<?php
echo $doc->zip;
?>
" maxlength="10"></td>
</tr>
<tr>
<td>Address is: </td>
<td align="right"><label><input name="ho" type="radio" value="2" <?php
if ($doc->ho == 2) {
echo 'checked';
}
?>
echo $doc->spouse_prof;
?>
" maxlength="50" title="Spouse profession" /></td>
<td> </td>
</tr>
<tr>
<td bgcolor="#E0E0FF" title="Spouse specialty, if physician">Spouse's Specialty, if physician:</td>
<td colspan="2" bgcolor="#E0E0FF" title="Spouse specialty, if physician"><?php
echo showSpecList($db, $doc->spouse_spec, 'spouse_spec');
?>
</td>
</tr>
<tr>
<td bgcolor="#E0E0FF" title="If born in the USA">Spouse's Home/Birth state:</td>
<td bgcolor="#E0E0FF"><?php
echo showStateList($db, $doc->spouse_state, 'spouse_state');
?>
</td>
<td bgcolor="#E0E0FF"> </td>
</tr>
<tr>
<td>Any Children?</td>
<td><label>
<input name="children" type="radio" value="1" <?php
echo $doc->children ? 'checked' : '';
?>
>
Yes</label>
<label>
<input name="children" type="radio" value="0" <?php
" size="50" maxlength="50">
Line 2:
<input name="ofaddr2" type="text" id="ofaddr2" value="<?php
echo $doc ? $doc->ofaddr2 : '';
?>
" size="45" maxlength="50"></td>
</tr>
<tr>
<td bgcolor="#E0E0FF">City:</td>
<td bgcolor="#E0E0FF"><input name="ofcity" type="text" id="ofcity" value="<?php
echo $doc ? $doc->ofcity : '';
?>
" maxlength="30"></td>
<td bgcolor="#E0E0FF">State:</td>
<td bgcolor="#E0E0FF"><?php
echo showStateList($resdb, $doc ? $doc->ofstate : '--', 'ofstate');
?>
</td>
<td bgcolor="#E0E0FF">Zip:</td>
<td bgcolor="#E0E0FF"><input name="ofzip" type="text" id="ofzip" value="<?php
echo $doc ? $doc->ofzip : '';
?>
" maxlength="10"></td>
</tr>
<tr>
<td>Home Phone:</td>
<td><input name="homephone" type="text" id="homephone" value="<?php
echo $doc ? $doc->homephone : '';
?>
" size="12" maxlength="16" onChange="checkPhoEx(homephone,'Home Phone',state,'Home State')">
<span id="chkemail" style="cursor:hand" title="Check Area code/State match" onClick="checkPhoEx2('homephone','Home Phone','state','Home State')"> <img src="images/bquestion.png" alt="?" width="16" height="16" border="0" align="absmiddle" title="Check Area code/State match" ></span></td>
" size="50" maxlength="100"/>
</td>
</tr>
<tr>
<td>City*:</td>
<td>
<input type="text" name="l_city" id="l_city" value="<?php
echo $locations->l_city;
?>
" size="25" maxlength="50"/>
</td>
</tr>
<tr>
<td >State*: </td>
<td><?php
echo showStateList($db, $locations->l_state, 'l_state');
?>
</td>
</tr>
<tr>
<td>Zip:</td>
<td>
<input type="text" name="l_zip" id="l_zip" value="<?php
echo $locations->l_zip;
?>
" size="10" maxlength="10"/>
</td>
</tr>
<tr>
<td>Status:</td>
<td><select name="l_status" id="l_status" onChange="opptoocheck()">