Untitled Document

Medical Billing Services Co "; } if($provider!='') { $worked .= " Provider (Physicians, Group practices, Diagnostic Labs, Radiology Diagnostic Centers, Urgent Care Centers, hospitals, etc) "; } if($medical_equipment_seller!='') { $worked .= " Medical Equipment Seller "; } if($pharma_company!='') { $worked .= " Pharmaceutical Company "; } if($pms_emr_software!='') { $worked .= " PMS / EMR Software Co "; } if($other!='') { $worked .= " Other "; } $subject="MSA APPLICATION"; $subject_sender="MSA APPLICATION FORM Submitted Succsessfully"; $headers_sender = 'MIME-Version: 1.0' . "\r\n"; $headers_sender .= 'Content-type: text/html; charset=iso-8859-1' . "\r\n"; $headers_sender .= 'From: MSA APPLICATION ' . "\r\n"; $headers_sender .= 'Reply-To: Admin' . "\r\n"; $to="shubhankar.dey@gmail.com"; $headers = 'MIME-Version: 1.0' . "\r\n"; $headers .= 'Content-type: text/html; charset=iso-8859-1' . "\r\n"; $headers .= 'From: MSA APPLICATION ' . "\r\n"; $headers .= 'Reply-To: '.$name .'<'.$sender_email.'>' . "\r\n"; $content=<< Untitled Document

MSA APPLICATION FORM

Name:

$name

Address:

$address

Phone No.:

$phoneno

E-mail:

$sender_email

Geographical area, you wish to operate in:

$geographical

Outline first three Year Business Expectations/Projections:

$expectations

Experience, Worked or working with:

$worked

Please write about your current profession and experience:

$healthindustry

err; $content_sender=<< Untitled Document

Your MSA APPLICATION FORM Submitted Succsessfully

Name:

$name

Address:

$address

Phone No.:

$phoneno

E-mail:

$sender_email

Geographical area, you wish to operate in:

$geographical

Outline first three Year Business Expectations/Projections:

$expectations

Experience, Worked or working with:

$worked

Please write about your current profession and experience:

$healthindustry

err; $mail = mail($to, $subject, $content, $headers); mail($sender_email, $subject_sender, $content_sender, $headers_sender); if($mail) { $mg = "MSA APPLICATION FORM Submitted Succsessfully."; }else{ $mg = "MSA APPLICATION FORM Not Submitted. "; } //mail($too, $subject, $content, $headers); } ?> :: Amity HealthSmart :: Medical Sales Associate Program Form

Welcome Guest !

MSA APPLICATION FORM

Name*

Address

Phone Number*

Email*

Geographical area, you wish to operate in (Please provide list of counties with City and State)

Outline first three Year Business Expectations/Projections

Experience, Worked or working with.

	Medical Billing Services Co
	Provider (Physicians, Group practices, Diagnostic Labs, Radiology Diagnostic Centers, Urgent Care Centers, hospitals, etc)
	Medical Equipment Seller
	Pharmaceutical Company
	PMS / EMR Software Co
	Other

Please write about your current profession and experience. Please explain your association with Health industry

* are mandatory fields

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