<?
ini_set('display_errors', 0);

include('classes/fpdf/fpdf.php');
include('classes/fpdi/fpdi.php');
include('classes/phpmailer/class.phpmailer.php');

if ($_POST[action]=="handleform")
{
  if ($_POST[q3]=="")
  {
    $error3 = 1;
  }
  if ($_POST[q4]=="")
  {
    $error4 = 1;
  }
  if ($_POST[q5])
  {
    if (!preg_match("/^[a-z0-9]+([_\\.-][a-z0-9]+)*@([a-z0-9]+([\.-][a-z0-9]+)*)+\\.[a-z]{2,}$/i", $_POST[q5]))
    {
      $error5 = 1;
    }
  }
  if (!$error3 && !$error4 && !$error5)
  {
    $q1 = stripslashes($_POST[q1]);
    $q1 = iconv('UTF-8', 'windows-1252', $q1);
    $q2 = stripslashes($_POST[q2]);
    $q2 = iconv('UTF-8', 'windows-1252', $q2);
    $q3 = stripslashes($_POST[q3]);
    $q3 = iconv('UTF-8', 'windows-1252', $q3);
    $q4 = stripslashes($_POST[q4]);
    $q4 = iconv('UTF-8', 'windows-1252', $q4);
    $q5 = stripslashes($_POST[q5]);
    $q5 = iconv('UTF-8', 'windows-1252', $q5);
    $q6 = stripslashes($_POST[q6]);
    $q6 = iconv('UTF-8', 'windows-1252', $q6);
    $q7 = stripslashes($_POST[q7]);
    $q7 = iconv('UTF-8', 'windows-1252', $q7);
    $q8 = stripslashes($_POST[q8]);
    $q8 = iconv('UTF-8', 'windows-1252', $q8);
    $q9 = stripslashes($_POST[q9]);
    $q9 = iconv('UTF-8', 'windows-1252', $q9);
    $q10 = stripslashes($_POST[q10]);
    $q10 = iconv('UTF-8', 'windows-1252', $q10);
    $q11 = stripslashes($_POST[q11]);
    $q11 = iconv('UTF-8', 'windows-1252', $q11);
    $q12 = stripslashes($_POST[q12]);
    $q12 = iconv('UTF-8', 'windows-1252', $q12);
    $q13 = stripslashes($_POST[q13]);
    $q13 = iconv('UTF-8', 'windows-1252', $q13);
    $q14 = stripslashes($_POST[q14]);
    $q14 = iconv('UTF-8', 'windows-1252', $q14);
    $q15 = stripslashes($_POST[q15]);
    $q15 = iconv('UTF-8', 'windows-1252', $q15);
    $q16 = stripslashes($_POST[q16]);
    $q16 = iconv('UTF-8', 'windows-1252', $q16);
    $q17 = stripslashes($_POST[q17]);
    $q17 = iconv('UTF-8', 'windows-1252', $q17);
    $q18 = stripslashes($_POST[q18]);
    $q18 = iconv('UTF-8', 'windows-1252', $q18);

    $q19 = stripslashes($_POST[q19]);
    $q19 = iconv('UTF-8', 'windows-1252', $q19);
    $q20 = stripslashes($_POST[q20]);
    $q20 = iconv('UTF-8', 'windows-1252', $q20);
    $q21 = stripslashes($_POST[q21]);
    $q21 = iconv('UTF-8', 'windows-1252', $q21);
    $q22 = stripslashes($_POST[q22]);
    $q22 = iconv('UTF-8', 'windows-1252', $q22);
    $q23 = stripslashes($_POST[q23]);
    $q23 = iconv('UTF-8', 'windows-1252', $q23);
    $q24 = stripslashes($_POST[q24]);
    $q24 = iconv('UTF-8', 'windows-1252', $q24);
    $q25 = stripslashes($_POST[q25]);
    $q25 = iconv('UTF-8', 'windows-1252', $q25);

    $pdf = new FPDI();
    $source = "docs/opzeggen.pdf";
    $pdf->setSourceFile($source);

    $pdf->AddFont('Calibri','','calibri.php');
    $pdf->SetFont('Calibri','','11');

    $pdf->AddPage();
    $tplIdx = $pdf->importPage(1);
    $pdf->useTemplate($tplIdx, 0, 0);
  
    $x = 49;
    $y = 41.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q1);

    if ($q2!="dd/mm/jj")
    {
      $x = 153;
      $y = 41.5;
      $pdf->SetXY($x, $y);
      $pdf->Write(0, $q2);
    }

    $x = 49;
    $y = 49.7;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q3);

    $x = 153;
    $y = 49.4;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q4);

    $x = 49;
    $y = 57.9;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q5);

    $x = 72;
    $y = 79.2;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q6);

    $x = 149;
    $y = 79.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q7);

    if ($_POST[q8]=="man")
    {
      $x = 72;
      $y = 87.1;
    }
    else
    {
      $x = 91;
      $y = 87.1;
    }
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');

    if ($q9!="dd/mm/jj")
    {
      $x = 149;
      $y = 87.1;
      $pdf->SetXY($x, $y);
      $pdf->Write(0, $q9);
    }

    $x = 72;
    $y = 98.7;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q10);

    $x = 149;
    $y = 98.6;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q11);

    $x = 72;
    $y = 105.9;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q12);

    $x = 149;
    $y = 105.9;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q13);

    $x = 72;
    $y = 118.1;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q14);

    $x = 165.7;
    $y = 117.8;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q15);

    $x = 72;
    $y = 125.3;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q16);

    $x = 72;
    $y = 132.6;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q17);

    $x = 13.5;
    $y = 153;
    $pdf->SetXY($x, $y);
    $pdf->MultiCell('179', '5', $q18, '0', 'L');

  if ($_POST[q19]=="1") {
    $x = 79.5;
    $y = 230;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[q20]=="1") {
    $x = 79.5;
    $y = 235.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[q21]=="1") {
    $x = 79.5;
    $y = 241.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[q22]=="1") {
    $x = 79.5;
    $y = 247;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[q23]!="") {
    $x = 116;
    $y = 233;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q23);
  }
  if ($_POST[q24]!="") {
    $x = 116;
    $y = 246;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q24);
  }
  if ($_POST[q25]!="") {
    $x = 156;
    $y = 246.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q25);
  }







    if ($_POST[type]=="download")
    {
      $pdf->Output('opzeggen.pdf', 'D');
    }
    elseif ($_POST[type]=="send")
    {
      $pdf->Output('var/opzeggen.pdf', 'F');

      $text = "<font size=\"2\" face=\"verdana\">";
      $text .= "Beste ".$_POST[q3].",<br><br>";
      $text .= "Bedankt voor het invullen van het opzeggingsformulier op onze website.<br><br>";
      $text .= "Met vriendelijke groet,<br><br>Loket Personenalarmering<br><br>";
      $text .= "</font>";
      $mail = new PHPMailer(true);
      $body = $text;
      $body = preg_replace('/\\\\/','', $body);
      //$mail->IsSMTP();
      $mail->Host = "localhost";
      $mail->AddReplyTo("info@loketpa.nl","Loket Personenalarmering");
      $mail->From = "info@loketpa.nl";
      $mail->FromName = "Loket Personenalarmering";
      if ($_POST[q5])
      {
        $mail->addAddress($_POST[q5]);
        $to = "afmelding@loketpa.nl";
        $mail->AddBCC($to);
      }
      else
      {
        $to = "afmelding@loketpa.nl";
        $mail->addAddress($to);
      }
      // $to = "bcc@connexx.nl";
      // $mail->AddBCC($to);
      $mail->AddAttachment('var/opzeggen.pdf', 'opzeggen.pdf');
      $mail->Subject = "Opzeggingsformulier $_POST[q6]";
      $mail->AltBody    = "To view the message, please use an HTML compatible email viewer!";
      $mail->WordWrap   = 80;
      $mail->MsgHTML($body);
      $mail->IsHTML(true);
      $mail->Send();
      $succes = 1;
    }
  }
}
?>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" />
<title>Loket Personenalarmering - Opzeggen</title>
<style type="text/css">
body {
	position : relative;
	margin-left: 0px;
	margin-top: 0px;
	margin-right: 0px;
	margin-bottom: 0px;
	background-color: #FFF;
}
.back-banner {
	background-image: url(images/back-banner.jpg);
	background-repeat: no-repeat;
	background-position: center top;
}
.backlinks2 {
	background-image: url(images/links-2.jpg);
	background-repeat: repeat-x;
	background-position: right top;
}
.backrechts2 {
	background-image: url(images/rechts-2.jpg);
	background-repeat: repeat-x;
	background-position: left top;
}
.backlinks1 {
	background-image: url(images/links-1.jpg);
	background-repeat: no-repeat;
	background-position: right top;
}
.backrechts1 {
	background-image: url(images/rechts-1.jpg);
	background-repeat: no-repeat;
	background-position: left top;
}
.back-kopje {
	background-image: url(images/back-1.gif);
	background-repeat: no-repeat;
	background-position: left top;
}
.kopje-blauw {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 26px;
	font-weight: normal;
	color: #54aac8;
}
.back-tekst-home {
	background-image: url(images/back-tekst.gif);
	background-repeat: no-repeat;
	background-position: left top;
}
.tekst-normal {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 14px;
	line-height: 22px;
	font-weight: normal;
	color: #366e81;
}
.tekst-normal-oranje {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 14px;
	line-height: 22px;
	font-weight: normal;
	color: #ffa61d;
}
.form-normaal {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 14px;
	line-height: 22px;
	font-weight: normal;
	color: #838383;
}
.tekst-normal-midden {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 14px;
	line-height: normal;
	font-weight: normal;
	color: #366e81;
	font-style: normal;
	font-variant: normal;
	text-align: center;
}
.tekst-highlight {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 16px;
	line-height: 20px;
	font-weight: bold;
	color: #ffa61d;
}
.tekst-subkop {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 18px;
	font-weight: normal;
	color: #ffa61d;
}
.back-footnoot {
	background-image: url(images/back-footnoot.gif);
	background-repeat: repeat-x;
	background-position: left top;
}
.tkest-footnoot {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 12px;
	line-height: 24px;
	font-weight: normal;
	color: #FFF;
}
a:link {
	color: #FFF;
	text-decoration: none;
}
a:visited {
	text-decoration: none;
	color: #FFF;
}
a:hover {
	text-decoration: none;
	color: #CFF;
}
a:active {
	text-decoration: none;
	color: #CFF;
}
.bigbirdmedia {
	background-image: url(images/bigbirdmedia.gif);
	background-repeat: no-repeat;
	background-position: left bottom;
}
.links-back1 {
	background-image: url(images/links-back-1.jpg);
	background-repeat: no-repeat;
	background-position: right top;
}
.links-back2 {
	background-image: url(images/links-back-2.gif);
	background-repeat: repeat-x;
	background-position: right top;
}
.rechts-back-1 {
	background-image: url(images/rechts-back-1.jpg);
	background-repeat: no-repeat;
	background-position: left top;
}
.rechts-back-2 {
	background-image: url(images/rechts-back-2.jpg);
	background-repeat: repeat-x;
	background-position: left top;
}
.back-baaner-2 {
	background-image: url(images/back-banner-2.jpg);
	background-repeat: no-repeat;
	background-position: left top;
}
.form-blauw {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 14px;
	font-weight: normal;
	color: #54aac8;
}
.onderschrift {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 11px;
	font-style: italic;
	font-weight: normal;
	color: #838383;
}
.oranje-kopje {
	font-family: Arial, Helvetica, sans-serif;
	font-size: 18px;
	font-weight: normal;
	color: #ffa61d;
}
input, textarea {
        border : 1px solid #BFBFBF;
}
.error {
	border : 1px solid #FF0000;
}
.popupbg {
	position : absolute;
	background-image : url('popups/succes-bg.png');
	height : 100%;
	width : 100%;
}
.popup {
	position : fixed;
	top : 169px;
	left : 50%;
	margin-left : -250px;
	cursor : pointer;
	border : 2px solid #FFE68C;
}

</style>
<script type="text/javascript" src="scripts/jquery-1.6.1.min.js"></script>
<script type="text/javascript">
  $(document).ready(function() {
    $("#verstuur").click(function() {
      $('#type').val('send');
      $('#formulier').submit();
    });
    $("#download").click(function() {
      $('#type').val('download');
      $('#formulier').submit();
    });
	$(".popup").click(function() {
		$(".popupbg").fadeOut();
	});
  });

  function textLimit(field,maxlen) {
    if(field.value.length > maxlen){
      while(field.value.length > maxlen){
        field.value=field.value.replace(/.$/,'');
      }
    }
  }
</script>
<script type="text/javascript">
function MM_swapImgRestore() { //v3.0
  var i,x,a=document.MM_sr; for(i=0;a&&i<a.length&&(x=a[i])&&x.oSrc;i++) x.src=x.oSrc;
}
function MM_preloadImages() { //v3.0
  var d=document; if(d.images){ if(!d.MM_p) d.MM_p=new Array();
    var i,j=d.MM_p.length,a=MM_preloadImages.arguments; for(i=0; i<a.length; i++)
    if (a[i].indexOf("#")!=0){ d.MM_p[j]=new Image; d.MM_p[j++].src=a[i];}}
}

function MM_findObj(n, d) { //v4.01
  var p,i,x;  if(!d) d=document; if((p=n.indexOf("?"))>0&&parent.frames.length) {
    d=parent.frames[n.substring(p+1)].document; n=n.substring(0,p);}
  if(!(x=d[n])&&d.all) x=d.all[n]; for (i=0;!x&&i<d.forms.length;i++) x=d.forms[i][n];
  for(i=0;!x&&d.layers&&i<d.layers.length;i++) x=MM_findObj(n,d.layers[i].document);
  if(!x && d.getElementById) x=d.getElementById(n); return x;
}

function MM_swapImage() { //v3.0
  var i,j=0,x,a=MM_swapImage.arguments; document.MM_sr=new Array; for(i=0;i<(a.length-2);i+=3)
   if ((x=MM_findObj(a[i]))!=null){document.MM_sr[j++]=x; if(!x.oSrc) x.oSrc=x.src; x.src=a[i+2];}
}
</script>
<meta name="Keywords" content="alarmering, personenalarmering, persoonsalarmering, zorgalarmering, ouderen alarmering, sociale alarmering, mobiele alarmering, zorgtelefoon, zorgopvolging, zorg drukknop, langer zelfstandig wonen, altijd veilig in huis, veiligheid, wmo, hulp" />
<meta name="Description" content="Personenalarmering voor welzijn en zorg. Langer zelfstandig thuis wonen. De hulp en zorg die u thuis nodig heeft, wanneer dan ook ...." />
</head>

<body onload="MM_preloadImages('images/home-b.gif','images/aanvragen-b.gif','images/wijzigen-b.gif','images/opzeggen-b.gif','images/storingen-b.gif','images/vragen-b.gif','images/contact-b.gif','images/download-b.gif','images/verstuur-opzeggen-b.gif')">

<?
if ($succes=="1") {
	?>
	<div class="popupbg">
		<div class="popup"><img src="popups/succes-afmelden.jpg"></div>
	</div>
	<?
}
?>

<table width="100%" border="0" cellspacing="0" cellpadding="0">
  <tr>
    <th align="right" valign="top" class="links-back2" scope="col">&nbsp;</th>
    <th width="459" height="372" align="right" valign="top" class="links-back1" scope="col">&nbsp;</th>
    <th width="1000" height="300" align="left" valign="top" class="back-baaner-2" scope="col"><table width="1000" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <th height="109" align="left" valign="top" scope="col">&nbsp;</th>
      </tr>
      <tr>
        <td align="left" valign="top"><a href="index.html" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('Image1','','images/home-b.gif',1)"><img src="images/home-a.gif" alt="" name="Image1" width="119" height="62" border="0" id="Image1" /></a><a href="aanvragen.html" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('Image2','','images/aanvragen-b.gif',1)"><img src="images/aanvragen-a.gif" alt="" name="Image2" width="159" height="62" border="0" id="Image2" /></a><a href="wijzigen.html" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('wijzigen','','images/wijzigen-b.gif',1)"><img src="images/wijzigen-a.gif" alt="alarmering" name="wijzigen" width="136" height="62" border="0" id="wijzigen" /></a><a href="opzeggen.html" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('opzeggen','','images/opzeggen-b.gif',1)"><img src="images/opzeggen-b.gif" alt="alarmering" name="opzeggen" width="147" height="62" border="0" id="opzeggen" /></a><a href="storingen.html" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('storingen','','images/storingen-b.gif',1)"><img src="images/storingen-a.gif" alt="loket alarm" name="storingen" width="148" height="62" border="0" id="storingen" /></a><a href="vragen.html" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('vragen','','images/vragen-b.gif',1)"><img src="images/vragen-a.gif" alt="personen" name="vragen" width="149" height="62" border="0" id="vragen" /></a><a href="contact.html" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('contact','','images/contact-b.gif',1)"><img src="images/contact-a.gif" alt="personenalarmering" name="contact" width="142" height="62" border="0" id="contact" /></a></td>
      </tr>
      <tr>
        <td height="177" align="left" valign="middle"><img src="images/banner-opzeggen.png" width="1000" height="123" alt="mantelzorg" /></td>
      </tr>
    </table></th>
    <th width="459" height="300" align="left" valign="top" class="rechts-back-1" scope="col">&nbsp;</th>
    <th align="left" valign="top" class="rechts-back-2" scope="col">&nbsp;</th>
  </tr>
  <tr>
    <th height="37" align="right" valign="top" bgcolor="#FFFFFF" scope="col">&nbsp;</th>
    <th rowspan="7" align="right" valign="top" scope="col">&nbsp;</th>
    <th width="1000" rowspan="7" align="left" valign="top" scope="col">
      <?
      if ($succes=="1")
      {
        ?>
        <br /><span class="kopje-blauw">Het formulier is succesvol verstuurd!</span><br /><span class="form-blauw">Wij zullen zo spoedig mogelijk uw opzegging verwerken en beantwoorden.</span>
        <?
      }
      else
      {
        ?>
      <table width="1000" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <th height="15" colspan="7" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
      <tr>
        <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
        <th width="170" height="30" align="left" valign="middle" class="form-blauw" scope="col">Instantie:</th>
        <th height="24" align="left" valign="middle" scope="col"><form id="formulier" method="post"><input name="q1" type="text" class="form-normaal" size="45" value="" /></th>
        <th width="46" align="left" valign="top" scope="col">&nbsp;</th>
        <th width="134" align="left" valign="middle" class="form-blauw" scope="col">Datum opzegging:</th>
        <th width="239" align="left" valign="middle" scope="col"><input onfocus="if (this.value=='dd/mm/jj') { this.value=''; };" onblur="if (this.value=='') { this.value='dd/mm/jj'; };" name="q2" type="text" class="form-normaal" size="28" value="<? if ($_POST[q2]) { ?><? } else { ?>dd/mm/jj<? } ?>" /></th>
        <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
      </tr>
      <tr>
        <th height="10" align="left" valign="top" scope="col">&nbsp;</th>
        <th height="10" align="left" valign="top" class="form-blauw" scope="col">&nbsp;</th>
        <th height="10" align="left" valign="top" class="onderschrift" scope="col">(indien van toepassing)</th>
        <th height="10" align="left" valign="top" scope="col">&nbsp;</th>
        <th height="10" align="left" valign="middle" class="form-blauw" scope="col">&nbsp;</th>
        <th height="10" align="left" valign="middle" scope="col">&nbsp;</th>
        <th height="10" align="left" valign="top" scope="col">&nbsp;</th>
      </tr>
      <tr>
        <th align="left" valign="top" scope="col">&nbsp;</th>
        <th height="30" align="left" valign="middle" class="form-blauw" scope="col">Naam:*</th>
        <th height="24" align="left" valign="middle" scope="col"><input name="q3" type="text" class="form-normaal<? if ($error3=="1") { ?> error<? } ?>" size="45" value=""/></th>
        <th align="left" valign="top" scope="col">&nbsp;</th>
        <th align="left" valign="middle" class="form-blauw" scope="col">Telefoon:*</th>
        <th align="left" valign="middle" scope="col"><input name="q4" type="text" class="form-normaal<? if ($error4=="1") { ?> error<? } ?>" size="28" value="" /></th>
        <th align="left" valign="top" scope="col">&nbsp;</th>
      </tr>
      <tr>
        <th align="left" valign="top" scope="col">&nbsp;</th>
        <th height="30" align="left" valign="middle" class="form-blauw" scope="col">Emailadres:</th>
        <th height="24" align="left" valign="middle" scope="col"><input name="q5" type="text" class="form-normaal<? if ($error5=="1") { ?> error<? } ?>" size="45" value="" /></th>
        <th align="left" valign="top" scope="col">&nbsp;</th>
        <th align="left" valign="top" class="form-blauw" scope="col">&nbsp;</th>
        <th align="left" valign="middle" scope="col">&nbsp;</th>
        <th align="left" valign="top" scope="col">&nbsp;</th>
      </tr>
      <tr>
        <th align="left" valign="top" scope="col">&nbsp;</th>
        <th height="24" align="left" valign="middle" class="form-blauw" scope="col">&nbsp;</th>
        <th height="24" align="left" valign="top" class="onderschrift" scope="col">(kopie van deze opzegging gaat naar dit emailadres)</th>
        <th align="left" valign="top" scope="col">&nbsp;</th>
        <th align="left" valign="top" class="form-blauw" scope="col">&nbsp;</th>
        <th align="left" valign="middle" scope="col">&nbsp;</th>
        <th align="left" valign="top" scope="col">&nbsp;</th>
      </tr>
    </table>
      <table width="1000" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <th height="30" colspan="8" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
          <th colspan="6" align="left" valign="top" class="kopje-blauw" scope="col">Deze opzegging heeft betrekking op:</th>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="26" colspan="6" align="left" valign="top" scope="col"><img src="images/schaduw-lijn.gif" width="952" height="26" alt="24 uur alarmering" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th width="170" rowspan="9" align="left" valign="top" scope="col"><img src="images/poppetje-persoongev.gif" width="170" height="184" alt="mantelzorg" /></th>
          <th width="124" height="30" align="left" valign="middle" class="form-normaal" scope="col">Naam:</th>
          <th width="239" align="left" valign="middle" scope="col"><input name="q6" type="text" class="form-normaal" size="31" value="" /></th>
          <th width="46" align="left" valign="top" scope="col">&nbsp;</th>
          <th width="134" align="left" valign="middle" class="form-normaal" scope="col">Voorletters:</th>
          <th width="239" align="left" valign="middle" scope="col"><input name="q7" type="text" class="form-normaal" size="28" value="" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="middle" class="form-normaal" scope="col">Geslacht:</th>
          <th align="left" valign="middle" scope="col"><table width="239" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <th width="22" align="left" valign="middle" scope="col"><input name="q8" <? if ($_POST[q8]=="man" || !$_POST[q8]) { ?>checked="checked"<? } ?> type="radio" class="form-normaal" value="man" /></th>
              <th width="85" align="left" valign="middle" class="form-normaal" scope="col">man</th>
              <th width="20" align="left" valign="middle" scope="col"><input name="q8" <? if ($_POST[q8]=="vrouw") { ?>checked="checked"<? } ?> type="radio" class="form-normaal" value="vrouw" /></th>
              <th width="112" height="30" align="left" valign="middle" class="form-normaal" scope="col">vrouw</th>
            </tr>
          </table></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="middle" class="form-normaal" scope="col">Geboortedatum:</th>
          <th align="left" valign="middle" scope="col"><input onfocus="if (this.value=='dd/mm/jj') { this.value=''; };" onblur="if (this.value=='') { this.value='dd/mm/jj'; };" name="q9" type="text" class="form-normaal" size="28" value="<? if ($_POST[q9]) { ?><? } else { ?>dd/mm/jj<? } ?>" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" colspan="5" align="left" valign="middle" class="form-normaal" scope="col"><img src="images/stippellijn.gif" width="782" height="29" alt="zorg" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="middle" class="form-normaal" scope="col">Straat + huisnr:</th>
          <th align="left" valign="middle" scope="col"><input name="q10" type="text" class="form-normaal" size="31" value="" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="middle" class="form-normaal" scope="col">Kamernr.<span class="onderschrift"> (optioneel):</span></th>
          <th align="left" valign="middle" scope="col"><input name="q11" type="text" class="form-normaal" size="28" value="" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="middle" class="form-normaal" scope="col">Postcode:</th>
          <th align="left" valign="middle" scope="col"><input name="q12" type="text" class="form-normaal" size="31" value="" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="middle" class="form-normaal" scope="col">Plaats:</th>
          <th align="left" valign="middle" scope="col"><input name="q13" type="text" class="form-normaal" size="28" value="" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" colspan="5" align="left" valign="middle" class="form-normaal" scope="col"><img src="images/stippellijn.gif" width="782" height="29" alt="zorg" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="middle" class="form-normaal" scope="col">Telefoon:</th>
          <th height="30" align="left" valign="middle" scope="col"><input name="q14" type="text" class="form-normaal" size="31" value=""/></th>
          <th height="30" align="left" valign="top" scope="col">&nbsp;</th>
          <th colspan="2" align="left" valign="middle" class="form-normaal" scope="col"><table width="373" border="0" cellspacing="0" cellpadding="0">
            <tr>
              <th style="color:#ffa61d;" width="187" height="30" align="left" valign="middle" class="form-normaal" scope="col">Code op het alarmapparaat:</th>
              <th width="186" height="30" align="left" valign="middle" scope="col"><input style="border:1px solid #ffa61d;" name="q15" type="text" class="form-normaal" size="19" value="" /></th>
            </tr>
          </table></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="middle" class="form-normaal" scope="col">Mobiel:</th>
          <th align="left" valign="middle" scope="col"><input name="q16" type="text" class="form-normaal" size="31" value="" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="middle" class="form-normaal" scope="col">&nbsp;</th>
          <th align="left" valign="middle" scope="col">&nbsp;</th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="middle" class="form-normaal" scope="col">Email:</th>
          <th align="left" valign="middle" scope="col"><input name="q17" type="text" class="form-normaal" size="31" value="" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="middle" class="form-normaal" scope="col">&nbsp;</th>
          <th align="left" valign="middle" scope="col">&nbsp;</th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
    </table>
      <table width="1000" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <th height="30" colspan="3" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
          <th height="40" align="left" valign="top" class="kopje-blauw" scope="col">Reden van opzegging</th>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="26" align="left" valign="top" scope="col"><img src="images/schaduw-lijn.gif" width="952" height="26" alt="24 uur alarmering" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="top" scope="col"><p>
            <textarea onkeyup="textLimit(this,800)" onblur="textLimit(this,800)" name="q18" cols="130" rows="10" class="form-normaal"></textarea><input type="hidden" name="action" value="handleform">
          </p></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        </table>
        <?
      }
      ?>
      <table width="1000" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <th height="30" colspan="3" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="top" class="kopje-blauw" scope="col">Inleveren apparatuur</th>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="26" align="left" valign="top" scope="col"><img src="images/schaduw-lijn.gif" width="952" height="26" alt="24 uur alarmering" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="top" class="form-blauw" scope="col">Het alarmapparaat kunt u inleveren bij de zorgpartner van LoketPersonenAlarmering.nl of opsturen naar het service centre van LoketPersonenAlarmering.nl.Bel 0413 - 273155 voor de dichtstbijzijnde zorgpartner.<br /><br />Adres Service Centre LoketPersonenAlarmering.nl: Postbus 425, 5400 AK Uden
          </th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th>&nbsp;</th>
          <th align="left" colspan="2">
            <table align="left">
              <tr height="15">
                <td colspan="4"></td>
              </tr>
              <tr>
                <td width="310"><span class="tekst-normal-oranje">Het alarmapparaat bestaat uit 4 onderdelen:</span></td>
                <td width="140"><span class="tekst-normal-oranje">Retour ontvangen:</span></td>
                <td colspan="2"><span class="tekst-normal-oranje">Ingeleverd door:</span></td>
              </tr>
              <tr>
                <td><span class="tekst-normal-oranje">1) alarm basisunit</span></td>
                <td><input name="q19" type="checkbox" class="form-normaal" id="checkbox1" <? if ($_POST[q19]=="1") { ?>checked="checked"<? } ?>value="1" /></td>
                <td colspan="2"><input style="border:1px solid #ffa61d;" name="q23" type="text" class="form-normaal" size="33" value="" /></td>
              </tr>
              <tr>
                <td><span class="tekst-normal-oranje">2) pols- of halszender</span></td>
                <td><input name="q20" type="checkbox" class="form-normaal" id="checkbox2" <? if ($_POST[q20]=="1") { ?>checked="checked"<? } ?>value="1" /></td>
                <td></td>
                <td></td>
              </tr>
              <tr>
                <td><span class="tekst-normal-oranje">3) 220V stroomadapter</span></td>
                <td><input name="q21" type="checkbox" class="form-normaal" id="checkbox3" <? if ($_POST[q21]=="1") { ?>checked="checked"<? } ?>value="1" /></td>
                <td><span class="tekst-normal-oranje">Datum:</span></td>
                <td><span class="tekst-normal-oranje">Telefoon:</span></td>
              </tr>
              <tr>
                <td><span class="tekst-normal-oranje">4) telefoonkabel</span></td>
                <td><input name="q22" type="checkbox" class="form-normaal" id="checkbox4" <? if ($_POST[q22]=="1") { ?>checked="checked"<? } ?>value="1" /></td>
                <td width="125"><input style="border:1px solid #ffa61d;" name="q24" type="text" class="form-normaal" size="12" value="" /></td>
                <td><input style="border:1px solid #ffa61d;" name="q25" type="text" class="form-normaal" size="12" value="" /><input id="type" type="hidden" name="type" value=""></form></td>
              </tr>
              <tr height="15">
                <td colspan="4"></td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th width="27" align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="top" class="form-blauw" scope="col">Per datum dat het complete alarmapparaat (4 onderdelen) retour is ontvangen bij een zorgpartner of bij het service centre van LoketPersonenAlarmering.nl wordt het abonnement stopgezet. De ingevulde datum van opzegging geldt enkel als kennisgeving.</th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
      </table>
      <table width="1000" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <th height="30" colspan="3" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="top" class="kopje-blauw" scope="col">Meer informatie</th>
          <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="26" align="left" valign="top" scope="col"><img src="images/schaduw-lijn.gif" width="952" height="26" alt="24 uur alarmering" /></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" rowspan="4" align="left" valign="top" class="form-normaal" scope="col">Voor meer informatie kunt u tijdens kantooruren contact met ons opnemen op telefoonnummer:<br />
          <span class="tekst-normal-oranje">0413 - 273 155</span> of via het e-mailadres: <span class="tekst-normal-oranje">info@loketpa.nl</span></th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="top" class="form-normaal" scope="col"><img style="cursor:pointer;<? if ($succes=="1") { ?> display:none;<? } ?>" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('verstuur','','images/verstuur-b.gif',1)" src="images/verstuur-a.gif" alt="24uur" name="verstuur" width="195" height="76" border="0" id="verstuur" /><img style="cursor:pointer;<? if ($succes=="1") { ?> display:none; <? } ?>"  onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('download','','images/download-b.gif',1)" src="images/download-a.gif" alt="mantelzorg" name="download" width="211" height="76" border="0" id="download" /><a href="docs/opzeggen.pdf" target="_blank"><img style="cursor:pointer;<? if ($succes=="1") {?> display:none; <? } ?>" onmouseout="MM_swapImgRestore()" onmouseover="MM_swapImage('leeg','','images/leeg-b.gif',1)" src="images/leeg-a.gif" alt="mantelzorg" name="leeg" width="211" height ="76" border="0" id="leeg" /></a></th>
           <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="30" align="left" valign="top" class="form-normaal" scope="col">&nbsp;</th>
          <th align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
    </table></th>
    <th rowspan="7" align="left" valign="top" class="bigbirdmedia" scope="col">&nbsp;</th>
    <th align="left" valign="top" scope="col">&nbsp;</th>
  </tr>
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    <th height="5" align="right" valign="top" bgcolor="#FFFFFF" scope="col">&nbsp;</th>
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  </tr>
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    <th height="29" align="right" valign="top" bgcolor="#FFFFFF" scope="col">&nbsp;</th>
    <th align="left" valign="top" scope="col">&nbsp;</th>
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    <th height="134" align="right" valign="top" bgcolor="#FFFFFF" scope="col">&nbsp;</th>
    <th align="left" valign="top" scope="col">&nbsp;</th>
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    <th height="1" align="right" valign="top" bgcolor="#FFFFFF" scope="col">&nbsp;</th>
    <th align="left" valign="top" scope="col">&nbsp;</th>
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    <th height="40" align="right" valign="top" bgcolor="#FFFFFF" scope="col">&nbsp;</th>
    <th align="left" valign="top" scope="col">&nbsp;</th>
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    <th height="1" align="right" valign="top" bgcolor="#FFFFFF" scope="col">&nbsp;</th>
    <th align="left" valign="top" scope="col">&nbsp;</th>
  </tr>
  <tr>
    <th align="right" valign="top" class="back-footnoot" scope="col">&nbsp;</th>
    <th height="100%" colspan="3" align="center" valign="top" class="back-footnoot" scope="col"><table width="1000" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <th width="27" align="left" valign="top" scope="col"><p>&nbsp;</p>
          <p>&nbsp;</p></th>
        <th width="13" align="left" valign="top" scope="col"><img src="images/schaduw.png" width="13" height="71" alt="zorgopvolging" /></th>
        <th width="74" align="left" valign="middle" class="tkest-footnoot" scope="col"><a href="index.html">home</a><br />
          <a href="contact.html">contact</a></th>
        <th width="13" align="left" valign="top" scope="col"><img src="images/schaduw.png" width="13" height="71" alt="zorgopvolging" /></th>
        <th width="83" align="left" valign="middle" class="tkest-footnoot" scope="col"><a href="aanvragen.html">aanvragen</a><br />
          <a href="wijzigen.html">wijzigen</a></th>
        <th width="13" align="left" valign="top" class="tkest-footnoot" scope="col"><img src="images/schaduw.png" width="13" height="71" alt="zorgopvolging" /></th>
        <th width="82" align="left" valign="middle" class="tkest-footnoot" scope="col"><a href="opzeggen.html">opzeggen</a><a href="opzeggen.html"></a><br />
          <a href="storingen.html">storingen</a></th>
        <th width="13" align="left" valign="middle" class="tkest-footnoot" scope="col"><img src="images/schaduw.png" width="13" height="71" alt="zorgopvolging" /></th>
        <th width="101" align="left" valign="middle" class="tkest-footnoot" scope="col"><a href="vragen.html">vragen ??</a><br />
          <br /></th>
        <th width="581" align="right" valign="middle" class="tkest-footnoot" scope="col">Loket PersonenAlarmering is een initiatief van verschillende gemeenten, welzijns- &amp; zorginstellingen</th>
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