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68.178.160.161  Public Scan

Form analysis
1 forms found in the DOM

POST transfer.php

<form action="transfer.php" method="post">
  <input type="hidden" name="jornaya_leadid" value="">
  <div class="row">
    <h4>Personal Details</h4>
    <div class="input-group input-group-icon">
      <input type="text" name="caller_id" placeholder="Phone Number" maxlength="10" pattern="[0-9]+" required="">
      <div class="input-icon"><i class="fa fa-phone"></i></div>
    </div>
    <div class="input-group input-group-icon">
      <select name="state" required="">
        <option value="AL">Alabama</option>
        <option value="AK">Alaska</option>
        <option value="AZ">Arizona</option>
        <option value="AR">Arkansas</option>
        <option value="CA">California</option>
        <option value="CO">Colorado</option>
        <option value="CT">Connecticut</option>
        <option value="DE">Delaware</option>
        <option value="DC">District Of Columbia</option>
        <option value="FL">Florida</option>
        <option value="GA">Georgia</option>
        <option value="HI">Hawaii</option>
        <option value="ID">Idaho</option>
        <option value="IL">Illinois</option>
        <option value="IN">Indiana</option>
        <option value="IA">Iowa</option>
        <option value="KS">Kansas</option>
        <option value="KY">Kentucky</option>
        <option value="LA">Louisiana</option>
        <option value="ME">Maine</option>
        <option value="MD">Maryland</option>
        <option value="MA">Massachusetts</option>
        <option value="MI">Michigan</option>
        <option value="MN">Minnesota</option>
        <option value="MS">Mississippi</option>
        <option value="MO">Missouri</option>
        <option value="MT">Montana</option>
        <option value="NE">Nebraska</option>
        <option value="NV">Nevada</option>
        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
        <option value="NY">New York</option>
        <option value="NC">North Carolina</option>
        <option value="ND">North Dakota</option>
        <option value="OH">Ohio</option>
        <option value="OK">Oklahoma</option>
        <option value="OR">Oregon</option>
        <option value="PA">Pennsylvania</option>
        <option value="RI">Rhode Island</option>
        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
        <option value="TX">Texas</option>
        <option value="UT">Utah</option>
        <option value="VT">Vermont</option>
        <option value="VA">Virginia</option>
        <option value="WA">Washington</option>
        <option value="WV">West Virginia</option>
        <option value="WI">Wisconsin</option>
        <option value="WY">Wyoming</option>
      </select>
      <div class="input-icon"><i class="fa fa-flag"></i></div>
    </div>
    <div class="input-group input-group-icon">
      <input type="text" name="landing_page" placeholder="Landing Page Url" required="">
      <div class="input-icon"><i class="fa fa-link"></i></div>
    </div>
    <!-- <div class="input-group input-group-icon">
        <input type="text" name="address" placeholder="Address" />
        <div class="input-icon"><i class="fa fa-envelope"></i></div>
      </div>
      <div class="input-group input-group-icon">
        <input type="text" name="address2" placeholder="Address 2 (Optional)"/>
        <div class="input-icon"><i class="fa fa-envelope"></i></div>
      </div>
      <div class="input-group input-group-icon">
        <input type="text" name="city" placeholder="City" />
        <div class="input-icon"><i class="fa fa-envelope"></i></div>
      </div>
      <div class="input-group input-group-icon">
        <input type="text" name="state" placeholder="State" />
        <div class="input-icon"><i class="fa fa-envelope"></i></div>
      </div> -->
  </div>
  <input type="submit" style="background-color: #7ed321; color: #fff;" name="" value="Submit">
</form>

Text Content

PERSONAL DETAILS


Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware
District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas
Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi
Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York
North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South
Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West
Virginia Wisconsin Wyoming