registrationscenter.com Open in urlscan Pro
63.135.225.238  Public Scan

Form analysis
1 forms found in the DOM

POST /renew/index.php

<form action="/renew/index.php" method="POST" id="renew-form" class="form-horizontal" autocomplete="off">
  <input type="hidden" name="step" value="1">
  <div class="row row-centered">
    <div class="col-md-4 col-md-offset-4">
      <noscript>
        <div class="bs-callout bs-callout-danger">
          <h4>JavaScript is not enabled!</h4>
          <p>This payment form requires your browser to have JavaScript enabled. Please activate JavaScript and reload this page. Check <a href="http://enable-javascript.com" target="_blank">enable-javascript.com</a> for more information.</p>
        </div>
      </noscript>
    </div>
  </div>
  <div class="alert alert-danger" id="a_x200" style="display: none;"> <strong>Error!</strong>
    <span class="payment-errors"></span>
  </div>
  <span class="payment-success">
  </span>
  <fieldset style="padding-left: 40px; padding-right: 40px">
    <div class="row">
      <div class="col-xs-12">
        <div style="background:#000080;color: white; width:auto;text-align:Center;">
          <h1 style="font-weight:bold;font-size:30px;font-family:Georgia,serif;padding:20px 1em ;">Start Form for Registration Renewal</h1>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-xs-6"><b>Entity Name <font color="red">*</font></b></div>
      <div class="col-xs-6"><b>Cage Code / UEI<font color="red">*</font></b></div>
    </div>
    <div class="row">
      <div class="col-xs-6">
        <input type="text" id="entity_name" name="entity_name" placeholder="" class="address form-control" value="MAZUMA CREDIT UNION">
      </div>
      <div class="col-xs-6">
        <input type="text" id="cage_code" name="cage_code" placeholder="" class="address form-control" value="7SAG8">
      </div>
    </div>
    <div class="row">
      <div class="col-xs-6"><b>First Name <font color="red">*</font></b></div>
      <div class="col-xs-6"><b>Last Name <font color="red">*</font></b></div>
    </div>
    <div class="row">
      <div class="col-xs-6">
        <input type="text" id="first_name" name="first_name" placeholder="" class="address form-control" value="Deonne">
      </div>
      <div class="col-xs-6">
        <input type="text" id="last_name" name="last_name" placeholder="" class="address form-control" value="Christensen">
      </div>
    </div>
    <div class="row">
      <div class="col-xs-6"><b>Position Held <font color="red">*</font></b></div>
      <div class="col-xs-6"><b></b></div>
    </div>
    <div class="row">
      <div class="col-xs-6">
        <select id="position_held" name="position_held" class="form-control">
          <option value="">- Please Choose - </option>
          <option value="Owner">Owner </option>
          <option value="Marketing">Marketing </option>
          <option value="CFO">CFO </option>
          <option value="Authorized Person">Authorized Person </option>
          <option value="COO">COO </option>
          <option value="CMO">CMO </option>
          <option value="Ceo" selected="">Ceo </option>
        </select>
      </div>
      <div class="col-xs-6">
      </div>
    </div>
    <div class="row">
      <div class="col-xs-6"><b>Contact Phone <font color="red">*</font></b></div>
      <div class="col-xs-6"><b>Extension</b></div>
    </div>
    <div class="row">
      <div class="col-xs-6">
        <input type="text" id="contact_phone" name="contact_phone" placeholder="" class="address form-control" value="9135745401">
      </div>
      <div class="col-xs-6">
        <input type="text" name="phone_extension" placeholder="" class="address form-control" value="">
      </div>
    </div>
    <div style="padding: 10px"> </div>
    <div class="row row-centered">
      <div class="col-md-4 col-md-offset-4">
        <input type="submit" name="submit" value="Next >>" class="btn btn-warning" onclick="if (check_form()) { return true; } else { return false; }">
      </div>
    </div>
    <div style="padding: 10px"> </div>
    <script>
      function check_form() {
        var required_fields = ["entity_name", "cage_code", "first_name", "last_name", "position_held", "contact_phone"];
        var error_messages = ["Entity Name", "Cage Code", "First Name", "Last Name", "Position Held", "Contact Phone"];
        var fields_len = required_fields.length;
        for (var i = 0; i < fields_len; i++) {
          if (document.getElementById(required_fields[i]).value == "") {
            document.getElementById(required_fields[i]).focus();
            alert("Error: " + error_messages[i] + " is a required field.");
            return false;
          }
        }
        return true;
      }
    </script>
  </fieldset>
</form>

Text Content

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activate JavaScript and reload this page. Check enable-javascript.com for more
information.

Error!


START FORM FOR REGISTRATION RENEWAL

Entity Name *
Cage Code / UEI*

First Name *
Last Name *

Position Held *

- Please Choose - Owner Marketing CFO Authorized Person COO CMO Ceo

Contact Phone *
Extension