converting from php4 to php5
<p>Please help, where i work dont have a inhouse tech and they rely on me for there needs. We have a application you fill out online and it e-mails the results of the app to an e-mail address. our web host server godaddy recently switched to PHP5 from PHP4 ( php 5.3) and now the applaction still shows on the website but when they submitt the app it e-mails us a blank application instead of the completed one. i called godaddy and they said our code or script that transmitts the data is not compatable with PHP5. i have pasted the code below and if anyone knows what i have to change to get this to work I would be greatly indebted to them and would help our business very much.  below is the code i need help with.
thank you for any insight you can provide</p>

<pre><code>&lt;!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-           

transitional.dtd"&gt;
&lt;html xmlns="http://www.w3.org/1999/xhtml"&gt;
&lt;head&gt;
&lt;meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" /&gt;
&lt;title&gt;Apply Online&lt;/title&gt;
&lt;link href="../css/default.css" rel="stylesheet" type="text/css" /&gt;
&lt;style type="text/css"&gt;
&lt;!--
.style1 {
font-size: 10px;
font-style: italic;
}
--&gt;
&lt;/style&gt;
&lt;/head&gt;

&lt;body&gt;
&lt;?php
foreach ($_POST as $k=&gt;$v) {$k = $v;}

$date = date(r);
?&gt;

&lt;table width="810" border="0" align="center" cellpadding="0" cellspacing="0"&gt;
&lt;tr&gt;
&lt;td colspan="3" align="left" valign="top"&gt;&lt;img src="../Images/GIF/Peterson_Cleaning_Logo_200x91.gif" alt="logo" width="200" height="91" /&gt;&lt;/td&gt;
&lt;td colspan="3" align="right" valign="middle"&gt;Peterson Cleaning, Inc.&lt;br /&gt;
  843 North Madison Street&lt;br /&gt;
  Rockford, IL. 61107&lt;br /&gt;
  Phone # 815.961.1300&lt;br /&gt;
Fax # 815.961.1190&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan="6" &gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;&lt;tr class="cell_title"&gt;
&lt;td colspan="6" align="left" valign="top" class="cell_title"&gt;&lt;p&gt;&amp;nbsp;&lt;/p&gt;
&lt;p&gt;Thank you, your application has been submitted.&lt;/p&gt;
&lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan="6" &gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;

&lt;/table&gt;
&lt;?php
$to = "applicant@petersoncleaning.com";
$subject = "$fname $mname $lname's Job Application";
$message = "&lt;table width='810' border='0' align='center' cellpadding='0' cellspacing='0'&gt;
&lt;td colspan='3' align='left' valign='top'&gt;&lt;img               

src='http://www.petersoncleaning.com/Images/GIF/Peterson_Cleaning_Logo_200x91.gif' alt='logo' width='200'                

height='91' /&gt;&lt;/td&gt;
&lt;td colspan='3' align='right' valign='middle'&gt;Peterson Cleaning, Inc.&lt;br /&gt;
  843 North Madison Street&lt;br /&gt;
  Rockford, IL. 61107&lt;br /&gt;
  Phone # 815.961.1300&lt;br /&gt;
Fax # 815.961.1190&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6'&gt;&amp;nbsp;&lt;/td&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_title'&gt;&lt;strong&gt;Application Information &lt;/strong&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt; First Name:
   &lt;strong&gt; $fname &lt;/strong&gt; 
  &lt;br /&gt;
Middle Name:
&lt;strong&gt; $mname &lt;/strong&gt; 
&lt;br /&gt;
Last Name:
&lt;strong&gt; $lname &lt;/strong&gt; 
&lt;br /&gt;&lt;/td&gt;
&lt;td colspan='4' class='cell_body_right_align'&gt; Address:
&lt;strong&gt; $address &lt;/strong&gt; 
Apt number
&lt;strong&gt; $apartment_number &lt;/strong&gt; 
&lt;br /&gt;
City:
&lt;strong&gt; $city &lt;/strong&gt; 
State:
&lt;strong&gt; $state &lt;/strong&gt; 
Zip:
&lt;strong&gt; $zip &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;&lt;td colspan='3' class='cell_body_center_align'&gt;Home Phone #:
&lt;strong&gt; $home_phone &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;&lt;span class='cell_body_left_align'&gt;Cell Phone #:
&lt;strong&gt; $cell_phone &lt;/strong&gt; 
&lt;/span&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='2' class='cell_body_center_align'&gt;Date Availible: &lt;span class='cell_body_right_align'&gt;&lt;span    

class='cell_body_left_align'&gt;
&lt;strong&gt; $date_availible &lt;/strong&gt; 
&lt;/span&gt;&lt;/span&gt;&lt;/td&gt;
&lt;td colspan='2' class='cell_body_center_align'&gt;Social Security #: &lt;span class='cell_body_left_align'&gt;&lt;span      

class='cell_body_right_align'&gt;
&lt;strong&gt; $soc_sec &lt;/strong&gt; 
&lt;/span&gt;&lt;/span&gt;&lt;/td&gt;
&lt;td colspan='2' class='cell_body_center_align'&gt;Desired Salary: &lt;span class='cell_body_left_align'&gt;&lt;span   

class='cell_body_right_align'&gt;
&lt;strong&gt; $desired_salary &lt;/strong&gt; 
&lt;/span&gt;&lt;/span&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;Position Applied for: &lt;span class='cell_body_left_align'&gt; &lt;strong&gt;   

$postion_applied_for &lt;/strong&gt;     &lt;/span&gt;&lt;/td&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;City Applied for: &lt;span class='cell_body_left_align'&gt;     

&lt;strong&gt;         
$city_applied_for &lt;/strong&gt;     &lt;/span&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;Email Address:      
   &lt;strong&gt; $email &lt;/strong&gt; 
&lt;span class='style1'&gt;(optional) &lt;/span&gt;&lt;/td&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;Birthdate: 
   &lt;strong&gt; $birthdate &lt;/strong&gt;  
&lt;span class='style1'&gt;(optional) &lt;/span&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
 &lt;td colspan='3' class='cell_body_center_align'&gt;&lt;p&gt;Are you a citizen of the United States? 
  &lt;br /&gt;&lt;strong&gt; $us_citizen &lt;/strong&gt; 
 &lt;/p&gt;&lt;/td&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;&lt;p&gt;If no, are you authorized to work in the U.S.? &lt;br /&gt;&lt;strong&gt;      

$authorized_in_us &lt;/strong&gt; 
&lt;/p&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;Have you ever worked for this company? &lt;br /&gt;&lt;strong&gt; $have_worked_for &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;If so, when? 
&lt;strong&gt; $worked_for_peterson_when &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='3' class='cell_body_center_align'&gt;Have you ever been convicted of a felony? &lt;br /&gt;&lt;strong&gt; $felony     

&lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body_center_align'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135' class='cell_body_center_align'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135' class='cell_body_center_align'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_center_align'&gt;If Yes, Explain: 
 &lt;strong&gt; $felony_because &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='6'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='6' class='cell_title'&gt;Education&lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;High School: 
 &lt;strong&gt; $hs &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='4' class='cell_body_right_align'&gt; Address:
 &lt;strong&gt; $hs_address &lt;/strong&gt; 
 &lt;br /&gt;
 City:
&lt;strong&gt; $hs_city &lt;/strong&gt; 
State:
&lt;strong&gt; $hs_state &lt;/strong&gt; 
Zip:
&lt;strong&gt; $hs_zip &lt;/strong&gt;     &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td width='135' class='cell_body_right_align'&gt;From:
&lt;strong&gt; $hs_from &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body_right_align'&gt;To:
&lt;strong&gt; $hs_to &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_center_align'&gt;Did you graduate? &amp;nbsp;&amp;nbsp;&amp;nbsp;&lt;strong&gt; $graduate_hs     

&lt;/strong&gt;     &lt;/td&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;College:
&lt;strong&gt; $college &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='4' class='cell_body_right_align'&gt; Address:
&lt;strong&gt; $college_address &lt;/strong&gt; 
&lt;br /&gt;
City:
   &lt;strong&gt; $college_city &lt;/strong&gt; 
  State:
   &lt;strong&gt; $college_state &lt;/strong&gt; 
  Zip:
 &lt;strong&gt; $college_zip &lt;/strong&gt;     &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td width='135' class='cell_body_right_align'&gt;From:
 &lt;strong&gt; $college_from &lt;/strong&gt; &lt;/td&gt;
 &lt;td width='135' class='cell_body_right_align'&gt;To:
 &lt;strong&gt; $college_to &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_center_align'&gt;Did you graduate? &amp;nbsp;&amp;nbsp;&amp;nbsp;&lt;strong&gt; $graduate_college   

 &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;Degree:
 &lt;strong&gt; $college_degree &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Other:
 &lt;strong&gt; $other &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='4' class='cell_body_right_align'&gt; Address:
 &lt;strong&gt; $other_address &lt;/strong&gt; 
  &lt;br /&gt;
  City:
   &lt;strong&gt; $other_city &lt;/strong&gt; 
  State:
   &lt;strong&gt; $other_state &lt;/strong&gt; 
  Zip:
 &lt;strong&gt; $other_zip &lt;/strong&gt;     &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td width='135' class='cell_body_right_align'&gt;From:
 &lt;strong&gt; $other_from &lt;/strong&gt; &lt;/td&gt;
 &lt;td width='135' class='cell_body_right_align'&gt;To:
 &lt;strong&gt; $other_to &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_center_align'&gt;Did you graduate? &amp;nbsp;&amp;nbsp;&amp;nbsp;&lt;strong&gt; $graduate_other  

&lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;Degree:
 &lt;strong&gt; $other_degree &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_title'&gt;References&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='2' class='cell_body_left_align'&gt;&lt;em&gt;Please list three references &lt;/em&gt;&lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='2' class='cell_body_left_align'&gt;Full Name: 
&lt;strong&gt; $ref1_name &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_left_align'&gt;Relationship:
&lt;strong&gt; $ref1_relation &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_left_align'&gt;Phone #:
&lt;strong&gt; $ref1_phone &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;Company:
&lt;strong&gt; $ref1_company &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='4' class='cell_body_right_align'&gt; Address:
&lt;strong&gt; $ref1_address &lt;/strong&gt; 
  &lt;br /&gt;
  City:
   &lt;strong&gt; $ref1_city &lt;/strong&gt; 
  State:
   &lt;strong&gt; $ref1_state &lt;/strong&gt; 
  Zip:
 &lt;strong&gt; $ref1_zip &lt;/strong&gt;     &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_left_align'&gt;Full Name:
 &lt;strong&gt; $ref2_name &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_left_align'&gt;Relationship:
 &lt;strong&gt; $ref2_relation &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_left_align'&gt;Phone #:
 &lt;strong&gt; $ref2_phone &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Company:
 &lt;strong&gt; $ref2_company &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='4' class='cell_body_right_align'&gt; Address:
 &lt;strong&gt; $ref2_address &lt;/strong&gt; 
 &lt;br /&gt;
 City:
 &lt;strong&gt; $ref2_city &lt;/strong&gt; 
 State:
 &lt;strong&gt; $ref2_state &lt;/strong&gt; 
 Zip:
 &lt;strong&gt; $ref2_zip &lt;/strong&gt;     &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_left_align'&gt;Full Name:
 &lt;strong&gt; $ref3_name &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_left_align'&gt;Relationship:
 &lt;strong&gt; $ref3_relation &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_left_align'&gt;Phone #:
 &lt;strong&gt; $ref3_phone &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Company:
 &lt;strong&gt; $ref3_company &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='4' class='cell_body_right_align'&gt; Address:
 &lt;strong&gt; $ref3_address &lt;/strong&gt; 
 &lt;br /&gt;
 City:
 &lt;strong&gt; $ref3_city &lt;/strong&gt; 
 State:
 &lt;strong&gt; $ref3_state &lt;/strong&gt; 
 Zip:
 &lt;strong&gt; $ref3_zip &lt;/strong&gt;     &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='6' class='cell_title'&gt;Previous Employment &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Company:
 &lt;strong&gt; $pe1_company &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Supervisor: 
 &lt;strong&gt; $pe1_suporvisor &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Phone #:
 &lt;strong&gt; $pe1_phone &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='4' class='cell_body_right_align'&gt; Address:
 &lt;strong&gt; $pe1_address &lt;/strong&gt;         
 &lt;br /&gt;
 City:
 &lt;strong&gt; $pe1_city &lt;/strong&gt; 
 State:
 &lt;strong&gt; $pe1_state &lt;/strong&gt; 
 Zip:
&lt;strong&gt; $pe1_zip &lt;/strong&gt;     &lt;/td&gt;
&lt;td width='135' class='cell_body_center_align'&gt;Starting Salary:
 &lt;strong&gt; $pe1_starting &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body_center_align'&gt;Ending Salary:
 &lt;strong&gt; $pe1_ending &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
  &lt;tr&gt;
  &lt;td colspan='6' class='cell_body_center_align'&gt;Responsibilities: 
  &lt;strong&gt; $pe1_responsibilities &lt;/strong&gt; &lt;/td&gt;
  &lt;/tr&gt;
  &lt;tr&gt;
  &lt;td width='135' class='cell_body_right_align'&gt;From:
  &lt;strong&gt; $pe1_from &lt;/strong&gt; &lt;/td&gt;
  &lt;td width='135' class='cell_body_right_align'&gt;To:
  &lt;strong&gt; $pe1_to &lt;/strong&gt; &lt;/td&gt;
  &lt;td colspan='4' class='cell_body_center_align'&gt;Reason for Leaving: 
  &lt;strong&gt; $pe1_reason &lt;/strong&gt; &lt;/td&gt;
  &lt;/tr&gt;
  &lt;tr&gt;
 &lt;td colspan='5' class='cell_body_center_align'&gt;May we contact your previous supervisor for a reference?&lt;strong&gt; 

$prev_employer1_can_we_contact &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;Company:
&lt;strong&gt; $pe2_company &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;Supervisor:
&lt;strong&gt; $pe2_suporvisor &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='2' class='cell_body_right_align'&gt;Phone #:
&lt;strong&gt; $pe2_phone &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='4' class='cell_body_right_align'&gt; Address:
&lt;strong&gt; $pe2_address &lt;/strong&gt; 
&lt;br /&gt;
City:
&lt;strong&gt; $pe2_city &lt;/strong&gt; 
State:
&lt;strong&gt; $pe2_state &lt;/strong&gt; 
Zip:
&lt;strong&gt; $pe2_zip &lt;/strong&gt;     &lt;/td&gt;
&lt;td width='135' class='cell_body_center_align'&gt;Starting Salary:
&lt;strong&gt; $pe2_starting &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body_center_align'&gt;Ending Salary:
&lt;strong&gt; $pe2_ending &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_center_align'&gt;Responsibilities:
 &lt;strong&gt; $pe2_responsibilities &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td width='135' class='cell_body_right_align'&gt;From:
&lt;strong&gt; $pe2_from &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body_right_align'&gt;To:
&lt;strong&gt; $pe2_to &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='4' class='cell_body_center_align'&gt;Reason for Leaving:
&lt;strong&gt; $pe2_reason &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='5' class='cell_body_center_align'&gt;May we contact your previous supervisor for a reference? &lt;strong&gt; 

 $prev_employer2_can_we_contact &lt;/strong&gt; &lt;/td&gt;
 &lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
 &lt;/tr&gt;

 &lt;tr&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Company:
 &lt;strong&gt; $pe3_company &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Supervisor:
 &lt;strong&gt; $pe3_suporvisor &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='2' class='cell_body_right_align'&gt;Phone #:
 &lt;strong&gt; $pe3_phone &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='4' class='cell_body_right_align'&gt; Address:
 &lt;strong&gt; $pe3_address &lt;/strong&gt; 
 &lt;br /&gt;
 City:
 &lt;strong&gt; $pe3_city &lt;/strong&gt; 
 State:
 &lt;strong&gt; $pe3_state &lt;/strong&gt; 
 Zip:
 &lt;strong&gt; $pe3_zip &lt;/strong&gt;     &lt;/td&gt;
 &lt;td width='135' class='cell_body_center_align'&gt;Starting Salary:
 &lt;strong&gt; $pe3_starting &lt;/strong&gt; &lt;/td&gt;
 &lt;td width='135' class='cell_body_center_align'&gt;Ending Salary:
 &lt;strong&gt; $pe3_ending &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='6' class='cell_body_center_align'&gt;Responsibilities:
 &lt;strong&gt; $pe3_responsibilities &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td width='135' class='cell_body_right_align'&gt;From:
 &lt;strong&gt; $pe3_from &lt;/strong&gt; &lt;/td&gt;
 &lt;td width='135' class='cell_body_right_align'&gt;To:
 &lt;strong&gt; $pe3_to &lt;/strong&gt; &lt;/td&gt;
 &lt;td colspan='4' class='cell_body_center_align'&gt;Reason for Leaving:
 &lt;strong&gt; $pe3_reason &lt;/strong&gt; &lt;/td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
&lt;td colspan='5' class='cell_body_center_align'&gt;May we contact your previous supervisor for a reference?&lt;strong&gt; $prev_employer3_can_we_contact &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;

&lt;tr&gt;
&lt;td colspan='6'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_title'&gt;Military Service &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='4' class='cell_body_left_align'&gt;Branch: 
&lt;strong&gt; $military_branch &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body_right_align'&gt;From:
&lt;strong&gt; $military_from &lt;/strong&gt; &lt;/td&gt;
&lt;td width='135' class='cell_body_right_align'&gt;To:
&lt;strong&gt; $military_to &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='3' class='cell_body_left_align'&gt;Rank at Discharge: 
&lt;strong&gt; $rank &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='3' class='cell_body_left_align'&gt;Type of Discharge: 
&lt;strong&gt; $type_of_discharge &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_left_align'&gt;If other than honorable, explain: 
&lt;strong&gt; $textfield6 &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_title'&gt;Questionaire&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='4' class='cell_body_left_align'&gt;&lt;em&gt;Please answer each question to the best of your ability. &lt;/em&gt;&lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135' class='cell_body'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6'&gt;&lt;p class='cell_body_left_align'&gt;Do you have any physical Condition that may limit your ability to perform the job for which you have applied?&lt;br /&gt;&lt;strong&gt; $has_physical_condition &lt;/strong&gt; 
    If yes, please explain: 
     &lt;strong&gt; $yes_physical_condition &lt;/strong&gt; 
 /td&gt;
 &lt;/tr&gt;
 &lt;tr&gt;
 &lt;td colspan='6' class='cell_body_left_align'&gt;Does heat, standing on your feet, or lifting cause you any difficulties?&lt;br /&gt;&lt;strong&gt; $standing &lt;/strong&gt; 
 If yes, please explain:
&lt;strong&gt; $yes_standing &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_left_align'&gt;My number one reason for seeking employment in a cleaning buisness  is:&lt;br /&gt; &lt;strong&gt; $reasond_for_seeking_employment &lt;/strong&gt;  &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_left_align'&gt;I am applying to Peterson Cleaning, Inc. because:&lt;br /&gt; &lt;strong&gt; $peterson_cleaning &lt;/strong&gt;  &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_left_align'&gt;My friends describe me as:&lt;br /&gt; &lt;strong&gt; $friends_describe_me_as  &lt;/strong&gt;  &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_left_align'&gt;My previous (or current) employer describes me as:&lt;br /&gt;
&lt;strong&gt; $previous_employer_describes_me_as &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_left_align'&gt;When considering dependability, thouroughness, or energy level I feel my strongest area is: &lt;br /&gt;
&lt;strong&gt; $strongest_area &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_left_align'&gt;When it comes to getting along with fellow employees I can always be counted on to: &lt;br /&gt;
&lt;strong&gt; $fellow_employees &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_title'&gt;Disclaimer and Agreement &lt;/td&gt;
&lt;/tr&gt;
&lt;tr class='cell_body_left_align'&gt;
&lt;td colspan='6'&gt;&lt;p&gt;I certify that my answers are true and complete to the best of my knowledge.&lt;/p&gt;
&lt;p&gt;If this application leads to employment, I understand that false or misleading information in my application  or  interview may result in my release.&lt;/p&gt;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_center_align'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td width='135' class='cell_body_center_align'&gt; &lt;strong&gt; $contact_previous_employers &lt;/strong&gt; &lt;/td&gt;
&lt;td colspan='5' class='cell_body_left_align'&gt;By checking the box to the left, I herby authorize and request any  present or former employer, school, police department, financial institution or other person having personal knowledge  about me, to furnish bearer (Peterson Cleaning, Inc.) with any and all information in their possession regarding me in  connection with an application for employment. A printout or photocopy of this authorization may be accepted with the  same authority as the original, and I specifically waive any written notice from any present or former employer who may  provide information based upon this authorized request. I understand this authorization is to be part of the submitted  application that I filled out. &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_center_align'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_center_align'&gt;By pressing the submit button, you agree to the terms expressed  above.&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_center_align'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td colspan='6' class='cell_body_center_align'&gt;Submitted  &lt;strong&gt; $date &lt;/strong&gt; &lt;/td&gt;
&lt;/tr&gt;
&lt;tr&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;td width='135'&gt;&amp;nbsp;&lt;/td&gt;
&lt;/tr&gt;
&lt;/table&gt;";
$headers = "MIME-Version: 1.0\r\n";
$headers .= "Content-type: text/html; charset=iso-8859-1\r\n";
$headers .= "Content-Transfer-Encoding: 7bit\r\n";
$headers .= "From: Webpage@petersoncleaning.com\r\n";
mail($to, $subject, $message , $headers);
?&gt;
&lt;/body&gt;
&lt;/html&gt;
</code></pre>
