<% 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 = "info@abnm.info" objCDO.To = "info@abnm.info" 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 & "First Name: " objCDO.TextBody = objCDO.TextBody & Request("First Name") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Last Name: " objCDO.TextBody = objCDO.TextBody & Request("Last Name") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Degree: " objCDO.TextBody = objCDO.TextBody & Request("Degree") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Home Street Address: " objCDO.TextBody = objCDO.TextBody & Request("Home Street Address") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Business Street Address: " objCDO.TextBody = objCDO.TextBody & Request("Business Street Address") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Insitution: " objCDO.TextBody = objCDO.TextBody & Request("Insitution") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Mail Stop: " objCDO.TextBody = objCDO.TextBody & Request("Mail Stop") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Home City: " objCDO.TextBody = objCDO.TextBody & Request("Home City") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Business City: " objCDO.TextBody = objCDO.TextBody & Request("Business City") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Home State: " objCDO.TextBody = objCDO.TextBody & Request("Home State") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Business State: " objCDO.TextBody = objCDO.TextBody & Request("Business State") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Home Zip Code: " objCDO.TextBody = objCDO.TextBody & Request("Home Zip Code") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Business Zip Code: " objCDO.TextBody = objCDO.TextBody & Request("Business Zip Code") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Home Country: " objCDO.TextBody = objCDO.TextBody & Request("Home Country") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Business Country: " objCDO.TextBody = objCDO.TextBody & Request("Business Country") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Home Phone Number: " objCDO.TextBody = objCDO.TextBody & Request("Home Phone Number") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Business Phone Number: " objCDO.TextBody = objCDO.TextBody & Request("Business Phone Number") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Fax Number: " objCDO.TextBody = objCDO.TextBody & Request("Fax Number") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Cell Number: " objCDO.TextBody = objCDO.TextBody & Request("Cell Number") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Pager: " objCDO.TextBody = objCDO.TextBody & Request("Pager") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Email Address 1: " objCDO.TextBody = objCDO.TextBody & Request("Email Address 1") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Email Address 2: " objCDO.TextBody = objCDO.TextBody & Request("Email Address 2") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Diplomat Number: " objCDO.TextBody = objCDO.TextBody & Request("Diplomat Number") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Type of Practice: " objCDO.TextBody = objCDO.TextBody & Request("Type of Practice") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Description of Practice: " objCDO.TextBody = objCDO.TextBody & Request("Description of Practice") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Years in IONM: " objCDO.TextBody = objCDO.TextBody & Request("Years in IONM") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Training Neurophysiologist: " objCDO.TextBody = objCDO.TextBody & Request("Training Neurophysiologist") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Percent of Practice devited to IONM: " objCDO.TextBody = objCDO.TextBody & Request("Percent of Practice devited to IONM") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "IONM Supervision percent: " objCDO.TextBody = objCDO.TextBody & Request("IONM Supervision percent") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "IONM technologist percent: " objCDO.TextBody = objCDO.TextBody & Request("IONM technologist percent") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "percent of research time: " objCDO.TextBody = objCDO.TextBody & Request("percent of research time") objCDO.TextBody = objCDO.TextBody & chr(10) & chr(13) objCDO.TextBody = objCDO.TextBody & "Comments: " objCDO.TextBody = objCDO.TextBody & Request("Comments") 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" ' Response.Write "Your Message has been sent. Thank you!" Response.End end if %>

American Board of
Neurophysiologic Monitoring

Exam Application   |   Requirements for Application   |   Written Exam   |   Oral Exam   |   Recertification   |   Policy and Procedures   |   Information Form   |   Official List of Diplomates   |   Officers and Board
">

ABNM Contact Information Form

First Name  Last Name Degree 
 Home Information Business Information
Home Street Address  Business Street Address
    Insitution/Company
    Mail Stop 
Home City  Business City 
Home State  Business State
Home Zip Code Business Zip Code 
Home Country  Business Country 
 Home Phone Number  Business Phone Number 
 Cell Number  Fax Number
     Pager 
Email Address 1  Email Address 2 
General Information  
Diplomat Number  
Type of Practice   
Description of Practice   
Years in IONM   
Training Neurophysiologist   
% of Practice devited to IONM   
IONM Supervision %  
IONM technologist %    
% of research time   
  
.

Copyright 2009 American Board of Neurophysiologic Monitoring
All rights reserved
For information on this website please contact webmaster@abnm.info
Last updated October 10, 2017