staging.redlumb.ae Open in urlscan Pro
74.208.175.159  Public Scan

Form analysis
1 forms found in the DOM

POST submit_form.php

<form dir="ltr" method="post" action="submit_form.php" class="col-12 mx-auto mt-1" enctype="multipart/form-data">
  <div class="d-flex flex-wrap justify-content-center gap-5 mb-3">
    <div class="col-3 mb-2">
      <input type="text" class="form-input" name="name" placeholder="FULL NAME">
    </div>
    <div class="col-3 mb-2">
      <input type="tel" class="form-input" name="contact" placeholder="CONTACT NO. +973">
    </div>
  </div>
  <div class="d-flex flex-wrap justify-content-center gap-5 mb-3">
    <div class="col-3 mb-2">
      <input type="email" class="form-input" name="email" placeholder="EMAIL ADDRESS">
    </div>
    <div class="col-3 mb-2">
      <label for="image" class="form-input-yellow-bg"> UPLOAD YOUR RECEIPT <input type="file" id="image" name="receipt" class="hidden">
      </label>
    </div>
    <div class="col-12 text-center">
      <div class="mb-3 form-check d-flex justify-content-center gap-4 my-3">
        <input type="hidden" name="locale" value="en" required="">
        <input type="checkbox" class="form-check-input" id="agreement" name="agreement" required="">
        <label class="form-check-label" for="agreement">I AGREE TO THE <a class="form-check-label" href="#">TERMS AND CONDITIONS</a></label>
      </div>
      <button type="submit" class="btn btn-form-submit my-4">SUBMIT</button>
    </div>
  </div>
</form>

Text Content

 * English

 * --------------------------------------------------------------------------------

 * العربية


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UPLOAD YOUR RECEIPT
I AGREE TO THE TERMS AND CONDITIONS
SUBMIT