secure.billtrust.com Open in urlscan Pro
192.69.130.34  Public Scan

Form analysis
1 forms found in the DOM

POST

<form id="eeForm" enctype="application/x-www-form-urlencoded" method="post" data-role="igvalidator" novalidate="novalidate">
  <div id="eeForm-errors" class="igvalidator-errors eeForm" style="display: none;"></div>
  <div class="fieldset">
    <div class="clearfix hideMobile"></div>
    <label for="eeName">Full Name:</label>
    <div class="input tooltipholder">
      <input name="eeName" type="text" value="" id="eeName" class="k-textbox tooltip" autocomplete="off" tabindex="1" data-role="igtooltip" required="">
      <span class="tooltiptext">Your full name</span>
    </div>
    <div class="clearfix hideMobile"></div>
    <label for="eeEmailAddress">Bill to eMail Address:</label>
    <div class="input tooltipholder">
      <input name="eeEmailAddress" type="email" value="" helper="formText" id="eeEmailAddress" class="k-textbox tooltip" autocomplete="off" tabindex="2" data-role="igtooltip" required="">
      <span class="tooltiptext">Enter an email address - example: johndoe@example.com</span>
    </div>
    <div class="clearfix hideMobile"></div>
    <div class="user-information">
      <h1>Account Information</h1>
      <p>
        <span>To verify your account(s), enter the following information found on your recent invoices.</span>
      </p>
    </div>
    <label for="eeAccountNumber">Account Number(s):</label>
    <div class="input tooltipholder">
      <input name="eeAccountNumber" type="text" value="" id="eeAccountNumber" class="k-textbox tooltip" autocomplete="off" tabindex="3" data-role="igtooltip" required="">
      <span class="tooltiptext">Account number(s) as listed on your invoices. Separate multiple account numbers using a comma. E.g. 100-12001, 100-12002, etc.</span>
    </div>
    <div class="clearfix hideMobile"></div>
    <label for="eeCompanyName">Company Name:</label>
    <div class="input tooltipholder">
      <input name="eeCompanyName" type="text" value="" id="eeCompanyName" class="k-textbox tooltip" autocomplete="off" tabindex="4" data-role="igtooltip" required="">
      <span class="tooltiptext">Company name as it appears on your invoice.</span>
    </div>
    <div class="terms">
      <div class="clearfix"></div>
      <div class="input checkbox">
        <input type="checkbox" name="eeack" value="1" helper="formCheckbox" id="eeack" tabindex="6" required="">
      </div>
      <label for="eeack"> I acknowledge that I will receive all of my invoices electronically and I will no longer receive paper invoices. </label>
    </div>
  </div>
  <div>
    <div id="captchaError" align="center" style="display: none;"><span style="color: red; font-weight: bold">Please click the captcha and try again.</span></div>
    <div class="g-recaptcha" data-sitekey="6LeXnzIUAAAAAGIcsVZrg8hG0PSRu9AxXjTOsdMa" data-callback="recaptcha_callback" align="center">
      <div style="width: 304px; height: 78px;">
        <div><iframe title="reCAPTCHA"
            src="https://www.google.com/recaptcha/api2/anchor?ar=1&amp;k=6LeXnzIUAAAAAGIcsVZrg8hG0PSRu9AxXjTOsdMa&amp;co=aHR0cHM6Ly9zZWN1cmUuYmlsbHRydXN0LmNvbTo0NDM.&amp;hl=de&amp;v=SglpK98hSCn2CroR0bKRSJl5&amp;size=normal&amp;cb=xyfy21fiqg0k"
            width="304" height="78" role="presentation" name="a-uhck4s8e9vmu" frameborder="0" scrolling="no" sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe>
        </div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
          style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
      </div><iframe style="display: none;"></iframe>
    </div>
  </div>
  <div class="btn-box">
    <input id="auto-email-enrollment-submit" name="auto-email-enrollment-submit" type="submit" value="Enroll Me" class="k-button size1" tabindex="7" disabled="">
    <span class="hint">Invoices will be sent to [<span id="emailText"><span>name@domain.ext</span></span>].</span>
  </div>
</form>

Text Content

English (United States)
 * English (United States)




EMAIL ENROLLMENT

To get started, please provide the information listed below.

*All fields are required


USER INFORMATION

Enter the bill to email address and contact name where you want to begin
receiving your electronic invoices.


Full Name:
Your full name

Bill to eMail Address:
Enter an email address - example: johndoe@example.com



ACCOUNT INFORMATION

To verify your account(s), enter the following information found on your recent
invoices.

Account Number(s):
Account number(s) as listed on your invoices. Separate multiple account numbers
using a comma. E.g. 100-12001, 100-12002, etc.

Company Name:
Company name as it appears on your invoice.

I acknowledge that I will receive all of my invoices electronically and I will
no longer receive paper invoices.
Please click the captcha and try again.

Invoices will be sent to [name@domain.ext].


EMAIL ENROLLMENT CONFIRMATION

Thank you for enrolling in electronic invoicing. You will begin receiving your
electronic invoices at . You will continue to receive paper invoices until your
account is updated. This may take up to a week.

If you need to change the email address you entered to receive electronic
invoicing, please contact customer service.
arinv@hologic.com