<?
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);
    $q26 = stripslashes($_POST[q26]);
    $q26 = iconv('UTF-8', 'windows-1252', $q26);
    $q27 = stripslashes($_POST[q27]);
    $q27 = iconv('UTF-8', 'windows-1252', $q27);
    $q28 = stripslashes($_POST[q28]);
    $q28 = iconv('UTF-8', 'windows-1252', $q28);
    $q29 = stripslashes($_POST[q29]);
    $q29 = iconv('UTF-8', 'windows-1252', $q29);
    $q30 = stripslashes($_POST[q30]);
    $q30 = iconv('UTF-8', 'windows-1252', $q30);
    $q31 = stripslashes($_POST[q31]);
    $q31 = iconv('UTF-8', 'windows-1252', $q31);
	$q32 = stripslashes($_POST[q32]);
    $q32 = iconv('UTF-8', 'windows-1252', $q32);
	$q33 = stripslashes($_POST[q33]);
    $q33 = iconv('UTF-8', 'windows-1252', $q33);
	$q34 = stripslashes($_POST[q34]);
    $q34 = iconv('UTF-8', 'windows-1252', $q34);
	$q35 = stripslashes($_POST[q35]);
    $q35 = iconv('UTF-8', 'windows-1252', $q35);
	$q36 = stripslashes($_POST[q36]);
    $q36 = iconv('UTF-8', 'windows-1252', $q36);
	$q37 = stripslashes($_POST[q37]);
    $q37 = iconv('UTF-8', 'windows-1252', $q37);
	$q38 = stripslashes($_POST[q38]);
    $q38 = iconv('UTF-8', 'windows-1252', $q38);
	$q39 = stripslashes($_POST[q39]);
    $q39 = iconv('UTF-8', 'windows-1252', $q39);
	$q40 = stripslashes($_POST[q40]);
    $q40 = iconv('UTF-8', 'windows-1252', $q40);
	$q41 = stripslashes($_POST[q41]);
    $q41 = iconv('UTF-8', 'windows-1252', $q41);
	$q42 = stripslashes($_POST[q42]);
    $q42 = iconv('UTF-8', 'windows-1252', $q42);
	$q43 = stripslashes($_POST[q43]);
    $q43 = iconv('UTF-8', 'windows-1252', $q43);
	$q44 = stripslashes($_POST[q44]);
    $q44 = iconv('UTF-8', 'windows-1252', $q44);
	$q45 = stripslashes($_POST[q45]);
    $q45 = iconv('UTF-8', 'windows-1252', $q45);
	$q46 = stripslashes($_POST[q46]);
    $q46 = iconv('UTF-8', 'windows-1252', $q46);
	$q47 = stripslashes($_POST[q47]);
    $q47 = iconv('UTF-8', 'windows-1252', $q47);
	$q48 = stripslashes($_POST[q48]);
    $q48 = iconv('UTF-8', 'windows-1252', $q48);
	$q49 = stripslashes($_POST[q49]);
    $q49 = iconv('UTF-8', 'windows-1252', $q49);
	$q50 = stripslashes($_POST[q50]);
    $q50 = iconv('UTF-8', 'windows-1252', $q50);
	$q51 = stripslashes($_POST[q51]);
    $q51 = iconv('UTF-8', 'windows-1252', $q51);
	$q52 = stripslashes($_POST[q52]);
    $q52 = iconv('UTF-8', 'windows-1252', $q52);
	$q53 = stripslashes($_POST[q53]);
    $q53 = iconv('UTF-8', 'windows-1252', $q53);
	$q54 = stripslashes($_POST[q54]);
    $q54 = iconv('UTF-8', 'windows-1252', $q54);
	$q55 = stripslashes($_POST[q55]);
    $q55 = iconv('UTF-8', 'windows-1252', $q55);
	$q56 = stripslashes($_POST[q56]);
    $q56 = iconv('UTF-8', 'windows-1252', $q56);
	$q57 = stripslashes($_POST[q57]);
    $q57 = iconv('UTF-8', 'windows-1252', $q57);
	$q58 = stripslashes($_POST[q58]);
    $q58 = iconv('UTF-8', 'windows-1252', $q58);
	$q59 = stripslashes($_POST[q59]);
    $q59 = iconv('UTF-8', 'windows-1252', $q59);
	$q60 = stripslashes($_POST[q60]);
    $q60 = iconv('UTF-8', 'windows-1252', $q60);
	$q61 = stripslashes($_POST[q61]);
    $q61 = iconv('UTF-8', 'windows-1252', $q61);
	$q62 = stripslashes($_POST[q62]);
    $q62 = iconv('UTF-8', 'windows-1252', $q62);
	$q63 = stripslashes($_POST[q63]);
    $q63 = iconv('UTF-8', 'windows-1252', $q63);
	$q64 = stripslashes($_POST[q64]);
    $q64 = iconv('UTF-8', 'windows-1252', $q64);
	$q65 = stripslashes($_POST[q65]);
    $q65 = iconv('UTF-8', 'windows-1252', $q65);
	$q66 = stripslashes($_POST[q66]);
    $q66 = iconv('UTF-8', 'windows-1252', $q66);
	$q67 = stripslashes($_POST[q67]);
    $q67 = iconv('UTF-8', 'windows-1252', $q67);
	$q68 = stripslashes($_POST[q68]);
    $q68 = iconv('UTF-8', 'windows-1252', $q68);
	$q69 = stripslashes($_POST[q69]);
    $q69 = iconv('UTF-8', 'windows-1252', $q69); 
	



    $qa88 = stripslashes($_POST[qa88]);
    $qa88 = iconv('UTF-8', 'windows-1252', $qa88);
    $qb88 = stripslashes($_POST[qb88]);
    $qb88 = iconv('UTF-8', 'windows-1252', $qb88);
    $qc88 = stripslashes($_POST[qc88]);
    $qc88 = iconv('UTF-8', 'windows-1252', $qc88);
    $qd88 = stripslashes($_POST[qd88]);
    $qd88 = iconv('UTF-8', 'windows-1252', $qd88);
    $qe88 = stripslashes($_POST[qe88]);
    $qe88 = iconv('UTF-8', 'windows-1252', $qe88);
    $qf88 = stripslashes($_POST[qf88]);
    $qf88 = iconv('UTF-8', 'windows-1252', $qf88);
    $qg88 = stripslashes($_POST[qg88]);
    $qg88 = iconv('UTF-8', 'windows-1252', $qg88);
    $qh88 = stripslashes($_POST[qh88]);
    $qh88 = iconv('UTF-8', 'windows-1252', $qh88);
    $qi88 = stripslashes($_POST[qi88]);
    $qi88 = iconv('UTF-8', 'windows-1252', $qi88);








    $pdf = new FPDI();
    $source = "docs/wijzigingen.pdf";
    $pdf->setSourceFile($source);

    $pdf->AddFont('Calibri','','calibri.php');
    $pdf->SetFont('Calibri','','11');

	$pdf->SetAutoPageBreak (off);
    $pdf->AddPage();
    $tplIdx = $pdf->importPage(1);
    $pdf->useTemplate($tplIdx, 0, 0);
	

	
  
    $x = 49;
    $y = 57.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q1);

    $x = 151;
    $y = 65.7;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q2);

    $x = 49;
    $y = 65.7;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q3);

    $x = 151;
    $y = 74;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q4);

    $x = 49;
    $y = 74;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q5);

    $x = 72;
    $y = 109.7;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q6);

    $x = 149;
    $y = 110;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q7);

    if ($_POST[q8]=="man")
    {
      $x = 72;
      $y = 117.6;
    }
    else
    {
      $x = 91;
      $y = 117.6;
    }
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');

	
	if ($q9!="dd/mm/jj")
    {
      $x = 149;
      $y = 117.6;
      $pdf->SetXY($x, $y);
      $pdf->Write(0, $q9);
    }

    $x = 72;
    $y = 129.2;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q10);

    $x = 149;
    $y = 129.1;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q11);

    $x = 72;
    $y = 136.4;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q12);

    $x = 149;
    $y = 136.4;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q13);

    $x = 72;
    $y = 148.6;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q14);

    $x = 165.7;
    $y = 148.3;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q15);

    $x = 72;
    $y = 155.7;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q16);

    $x = 72;
    $y = 163.1;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $q17); 


  if ($_POST[qa88]=="1") {
    $x = 12.5;
    $y = 210;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }

  if ($_POST[qb88]=="1") {
    $x = 50.5;
    $y = 210;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }

  if ($_POST[qc88]=="1") {
    $x = 92;
    $y = 210;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[qd88]=="1") {
    $x = 12.5;
    $y = 216.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[qe88]=="1") {
    $x = 50.5;
    $y = 216.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[qf88]=="1") {
    $x = 92;
    $y = 216.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[qg88]=="1") {
    $x = 12.5;
    $y = 239;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, 'X');
  }
  if ($_POST[qh88]!="") {
    $x = 40;
    $y = 253.5;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $qh88);
  }
  if ($_POST[qi88]!="") {
    $x = 40;
    $y = 244;
    $pdf->SetXY($x, $y);
    $pdf->Write(0, $qi88);
  }





	
	$pdf->AddPage();
	$tplIdx = $pdf->importPage(2);
	$pdf->useTemplate($tplIdx, 0, 0);
	
    $x = 13;
    $y = 53;
    $pdf->SetXY($x, $y);
    $pdf->MultiCell('182', '5', $q69, '0', 'L');





	if ($_POST[type]=="download")
    {
      $pdf->Output('wijzigingen.pdf', 'D');
    }
    elseif ($_POST[type]=="send")
    {
      $pdf->Output('var/wijzigingen.pdf', 'F');

      $text = "<font size=\"2\" face=\"verdana\">";
      $text .= "Beste ".$_POST[q3].",<br><br>";
      $text .= "Bedankt voor het invullen van het wijzigingsformulier 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 = "wijziging@loketpa.nl";
        $mail->AddBCC($to);
      }
      else
      {
        $to = "wijziging@loketpa.nl";
        $mail->addAddress($to);
      }
      // $to = "bcc@connexx.nl";
      // $mail->AddBCC($to);
      $mail->AddAttachment('var/wijzigingen.pdf', 'wijzigingen.pdf');
      $mail->Subject = "Wijzigingsformulier $_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 - Wijzigen</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-wijzig-b.png')">

<?
if ($succes=="1") {
	?>
	<div class="popupbg">
		<div class="popup"><img src="popups/succes-wijziging.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-b.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-a.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-wijzigen.png" width="1000" height="122" 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 ($succes=="1")
      {
        ?>
        <br /><span class="kopje-blauw">Het formulier is succesvol verstuurd!</span><br /><span class="form-blauw">Wij zullen zo spoedig mogelijk uw wijziging verwerken en beantwoorden.</span>
        <?
      }
      else
      {
        ?>
	<table width="1000" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <th height="15" colspan="7" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
      <tr>
        <th width="24" align="left" valign="top" scope="col">&nbsp;</th>
        <th width="170" height="30" align="left" valign="middle" class="form-blauw" scope="col">Instantie:</th>
        <th height="24" align="left" valign="middle" scope="col"><form id="formulier" method="post"><input name="q1" value="" type="text" class="form-normaal" id="textfield" size="45" /></th>
        <th width="46" align="left" valign="top" scope="col">&nbsp;</th>
        <th width="134" align="left" valign="middle" class="form-blauw" scope="col">Datum wijziging:</th>
        <th width="239" align="left" valign="middle" scope="col"><input onfocus="if (this.value=='dd/mm/jj') { this.value=''; };" onblur="if (this.value=='') { this.value='dd/mm/jj'; };" name="q2" type="text" class="form-normaal" size="28" value="<? if ($_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 wijziging 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 wijziging 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" value="" type="text" class="form-normaal" id="textfield6" size="31" /></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" value="" type="text" class="form-normaal" id="textfield12" size="28" /></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" || !$_POST[q8]) { ?>checked="checked"<? } ?> type="radio" class="form-normaal" value="man" id="checkbox" /></th>
              <th width="85" align="left" valign="middle" class="form-normaal" scope="col">man</th>
              <th width="20" align="left" valign="middle" scope="col"><input name="q8" <? if ($_POST[q8]=="vrouw") { ?>checked="checked"<? } ?> type="radio" class="form-normaal" value="vrouw" id="checkbox2" /></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" value="<? if ($_POST[q9]) { ?><? } else { ?>dd/mm/jj<? } ?>" type="text" class="form-normaal" id="textfield13" value="" size="28" /></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" value="" type="text" class="form-normaal" id="textfield7" size="31" /></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" value="" type="text" class="form-normaal" id="textfield14" size="28" /></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" value="" type="text" class="form-normaal" id="textfield8" size="31" /></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" value="" type="text" class="form-normaal" id="textfield15" size="28" /></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" value="" type="text" class="form-normaal" id="textfield9" size="31" /></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" value="" type="text" class="form-normaal" id="textfield16" size="19" /></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" value="" type="text" class="form-normaal" id="textfield10" size="31" /></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" value="" type="text" class="form-normaal" id="textfield11" size="31" /></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="4" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th width="24" rowspan="2" align="left" valign="top" scope="col">&nbsp;</th>
          <th height="40" colspan="2" align="left" valign="top" class="kopje-blauw" scope="col">Type wijziging</th>
          <th width="24" rowspan="2" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th colspan="2" align="left" valign="top" class="kopje-blauw" scope="col"><span class="form-blauw">* Geef bij wijzigingen van hulpverleners de volgende gegevens door:<br />De naam, adres, telefoon, reistijd naar woning en de volgorde waarin de hulpverleners gebeld moeten worden.</span></th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="26" colspan="2" 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="167" height="30" align="left" valign="top" class="form-normaal" scope="col">Uw wijziging:</th>
          <th width="785" align="left" valign="top" scope="col">
            <table width="658" border="0" cellpadding="0" cellspacing="0">
              <tr>
                <th width="25" height="30" align="left" valign="middle" scope="col"><input name="qa88" type="checkbox" class="form-normaal" id="checkbox19" <? if ($_POST[qa88]=="1") { ?>checked="checked"<? } ?> value="1"/></th>
                <th height="30" align="left" valign="middle" class="form-normaal" scope="col">Adres</th>
                <th width="25" height="30" align="left" valign="middle" scope="col"><input name="qb88" type="checkbox" class="form-normaal" id="checkbox21" <? if ($_POST[qb88]=="1") { ?>checked="checked"<? } ?> value="1" /></th>
                <th height="30" align="left" valign="middle" scope="col"><span class="form-normaal">Hulpverleners *</span></th>
                <th width="25" height="30" align="left" valign="middle" scope="col"><input name="qc88" type="checkbox" class="form-normaal" id="checkbox23" <? if ($_POST[qc88]=="1") { ?>checked="checked"<? } ?>value="1" /></th>
                <th height="30" align="left" valign="middle" scope="col"><span class="form-normaal">Huisarts</span></th>
                <th width="25" height="30" align="left" valign="middle" scope="col">&nbsp;</th>
                <th height="30" align="left" valign="middle" scope="col">&nbsp;</th>
              </tr>
              <tr>
                <td width="25" height="30" align="left" valign="middle"><input name="qd88" type="checkbox" class="form-normaal" id="checkbox20" <? if ($_POST[qd88]=="1") { ?>checked="checked"<? } ?> value="1" /></td>
                <td height="30" align="left" valign="middle"><span class="form-normaal">Verzekering</span></td>
                <td width="25" height="30" align="left" valign="middle"><input name="qe88" type="checkbox" class="form-normaal" id="checkbox22" <? if ($_POST[qe88]=="1") { ?>checked="checked"<? } ?> value="1" /></td>
                <td height="30" align="left" valign="middle"><span class="form-normaal">Regelpersoon</span></td>
                <td width="25" height="30" align="left" valign="middle"><input name="qf88" type="checkbox" class="form-normaal" id="checkbox25" <? if ($_POST[qf88]=="1") { ?>checked="checked"<? } ?> value="1" /></td>
                <td height="30" align="left" valign="middle"><span class="form-normaal">Overig</span></td>
                <td width="25" height="30" align="left" valign="middle">&nbsp;</td>
                <td height="30" align="left" valign="middle">&nbsp;</td>
              </tr>
            <tr height="25">
              <td colspan="8"></td>
            </tr>
            <tr>
              <td width="25" height="30" align="left" valign="middle"><input name="qg88" type="checkbox" class="form-normaal" id="checkbox20" <? if ($_POST[qg88]=="1") { ?>checked="checked"<? } ?> value="1" /></td>
              <td colspan="7" height="30" align="left" valign="middle"><span style="color:#ffa61d;" class="form-normaal">Vervanging apparaat door partner van loketpa.nl</span></td>
            </tr>
            <tr>
              <td colspan="8">
                <table>
                  <tr>
                    <th style="color:#ffa61d;" height="10" colspan="2" align="left" valign="middle" class="onderschrift" scope="col">(in te vullen door partner loketpa.nl)</th>
                  </tr>
                  <tr>
                    <th style="color:#ffa61d;" width="90" height="30" align="left" valign="middle" class="form-normaal" scope="col">Oude code:</th>
                    <th height="30" align="left" valign="middle" scope="col"><input style="border:1px solid #ffa61d;" name="qh88" type="text" class="form-normaal" size="19" value="" /></td>
                  </tr>
                  <tr>
                    <th style="color:#ffa61d;" width="90" height="30" align="left" valign="middle" class="form-normaal" scope="col">Nieuwe code:</th>
                    <th height="30" align="left" valign="middle" scope="col"><input style="border:1px solid #ffa61d;" name="qi88" type="text" class="form-normaal" size="19" value="" /</td>
                  </tr>
                </table>
              </td>
            </tr>
            </table>
          </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="4" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th width="24" rowspan="2" align="left" valign="top" scope="col">&nbsp;</th>
          <th height="40" colspan="2" align="left" valign="top" class="kopje-blauw" scope="col">Uw wijzigingen</th>
          <th width="24" rowspan="2" align="left" valign="top" scope="col">&nbsp;</th>
        </tr>
        <tr>
          <th colspan="2" align="left" valign="top" class="kopje-blauw" scope="col"><span class="form-blauw">Geef uw wijzigingen hieronder door.</span></th>
        </tr>
        <tr>
          <th align="left" valign="top" scope="col">&nbsp;</th>
          <th height="26" colspan="2" 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="167" height="30" align="left" valign="top" class="form-normaal" scope="col">Uw wijziging:</th>
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	     <?
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          <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>
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