members.coquinsdefrance.com Open in urlscan Pro
2a06:98c1:3121::3  Public Scan

Submitted URL: https://go.coquinsdefrance.com/t/c/96da6cb076922bc1c3d569ad5fe92214.fdf075e1d67f412b1ddcfd5f72fe1112?id=aHR0cDovL2NvcXVpbnNkZWZ...
Effective URL: https://members.coquinsdefrance.com/payment
Submission: On March 26 via api from BE — Scanned from NL

Form analysis 1 forms found in the DOM

POST

<form method="post" onsubmit="return false;" id="RocketGateForm">
  <div id="formWrapper">
    <div id="RocketGateFailed" style="display:none; width: 100%; color: rgb(213, 69, 83); background-color: rgba(213, 69, 83, 0.25); position: relative; top: -15px;">
      <p id="RocketGateErrorMessage" class="errorMSG" style="text-align: center; position: relative; top: -5px;"></p>
    </div>
    <div class="header">
      <h2>Achat Sécurisé</h2>
    </div>
    <p id="rg_ErrorMessage" class="errorMSG" style="display: none;"></p>
    <div id="cardData">
      <div id="divemail">
        <p class="required">
          <label for="rg_Email">Email:</label>
          <input type="email" id="rg_Email" value="jan.roose2@telenet.be" class="required" onblur="checkInput('rg_Email');" title="E-mail" size="30" maxlength="64" required="" onchange="RocketPayFindWallet(this);">
        </p>
      </div>
      <div id="divfname" style="display: inline-block;">
        <p class="required">
          <label for="rg_Fname">Prénom:</label>
          <input type="text" id="rg_Fname" value="" class="required" onblur="checkInput('rg_Fname');" title="Prénom" size="30" maxlength="32" required="" placeholder="Prénom">
        </p>
      </div>
      <div id="divlname" style="display: inline-block;">
        <p class="required">
          <label for="rg_Lname" style="display: none;">Nom du titulaire de la Carte:</label>
          <input type="text" id="rg_Lname" value="" class="required" onblur="checkInput('rg_Lname');" title="Nom" size="30" maxlength="32" required="" placeholder="Nom">
        </p>
      </div>
      <div id="divcardno">
        <p class="required">
          <label for="rg_Cardno">Numéro de carte:</label>
          <input type="text" id="rg_Cardno" value="" class="required" onblur="checkClearedCardNo(this);" onchange="displayAddrFields();" onclick="clearCardNo(this)" title="Numéro de la carte" size="19" maxlength="19" required="" autocomplete="OFF"
            placeholder="Numéro de la Carte">
        </p>
        <input type="HIDDEN" id="rg_CSRFToken" value="10855219925913916647729779998619845300305204156869043499472426175261251929372">
      </div>
      <div id="divcvv">
        <span>
          <p class="required">
            <label for="rg_Cvv2">CVV2:</label>
            <input type="text" id="rg_Cvv2" value="" class="required" onblur="checkInput('rg_Cvv2');" title="CVV" size="4" maxlength="4" required="" autocomplete="OFF" placeholder="CVV2">
          </p>
        </span>
      </div>
      <div id="divexpire">
        <p class="required">
          <label for="rg_Expire_month">Date d´expiration:</label>
          <span>
            <select id="rg_Expire_month" class="selectOne" title="Date d’expiration" onchange="checkInput('rg_Expire_month');" required="">
              <option value=""> MM</option>
              <option value="1"> 01 - Jan</option>
              <option value="2"> 02 - Feb</option>
              <option value="3"> 03 - Mar</option>
              <option value="4"> 04 - Apr</option>
              <option value="5"> 05 - May</option>
              <option value="6"> 06 - Jun</option>
              <option value="7"> 07 - Jul</option>
              <option value="8"> 08 - Aug</option>
              <option value="9"> 09 - Sep</option>
              <option value="10"> 10 - Oct</option>
              <option value="11"> 11 - Nov</option>
              <option value="12"> 12 - Dec</option>
            </select>
          </span>
          <span>
            <select id="rg_Expire_year" class="selectOne" title="Date d’expiration" onchange="checkInput('rg_Expire_year');" required="">
              <option value=""> YYYY</option>
              <option value="23"> 2023</option>
              <option value="24"> 2024</option>
              <option value="25"> 2025</option>
              <option value="26"> 2026</option>
              <option value="27"> 2027</option>
              <option value="28"> 2028</option>
              <option value="29"> 2029</option>
              <option value="30"> 2030</option>
              <option value="31"> 2031</option>
              <option value="32"> 2032</option>
              <option value="33"> 2033</option>
              <option value="34"> 2034</option>
              <option value="35"> 2035</option>
              <option value="36"> 2036</option>
              <option value="37"> 2037</option>
              <option value="38"> 2038</option>
              <option value="39"> 2039</option>
              <option value="40"> 2040</option>
              <option value="41"> 2041</option>
              <option value="42"> 2042</option>
            </select>
          </span>
        </p>
      </div>
      <div id="divzip" style="display: none;">
        <p class="required">
          <label for="rg_Zip">Code Postal:</label>
          <input type="text" id="rg_Zip" value="3044" class="" onblur="checkInput('rg_Zip');" title="Code Postal" size="30" maxlength="10" required="">
        </p>
      </div>
      <div id="divcountry" style="display: block;">
        <p class="required">
          <label for="rg_Country">Pays:</label>
          <select id="rg_Country" class="selectOne" title="Pays" onchange="checkInput('rg_Country');" required="">
            <option value="">Please select your country</option>
            <option value="US">UNITED STATES OF AMERICA</option>
            <option value="AU">AUSTRALIA</option>
            <option value="CA">CANADA</option>
            <option value="FR">FRANCE</option>
            <option value="DE">GERMANY</option>
            <option value="JP">JAPAN</option>
            <option value="GB">UNITED KINGDOM (GREAT BRITAIN)</option>
            <option value="---">------------</option>
            <option value="AF">AFGHANISTAN</option>
            <option value="AX">ALAND ISLANDS</option>
            <option value="AL">ALBANIA</option>
            <option value="DZ">ALGERIA</option>
            <option value="AS">AMERICAN SAMOA</option>
            <option value="AD">ANDORRA</option>
            <option value="AO">ANGOLA</option>
            <option value="AI">ANGUILLA</option>
            <option value="AQ">ANTARCTICA</option>
            <option value="AG">ANTIGUA AND BARBUDA</option>
            <option value="AR">ARGENTINA</option>
            <option value="AM">ARMENIA</option>
            <option value="AW">ARUBA</option>
            <option value="AU">AUSTRALIA</option>
            <option value="AT">AUSTRIA</option>
            <option value="AZ">AZERBAIJAN</option>
            <option value="BS">BAHAMAS</option>
            <option value="BH">BAHRAIN</option>
            <option value="BD">BANGLADESH</option>
            <option value="BB">BARBADOS</option>
            <option value="BE">BELGIUM</option>
            <option value="BZ">BELIZE</option>
            <option value="BJ">BENIN</option>
            <option value="BM">BERMUDA</option>
            <option value="BT">BHUTAN</option>
            <option value="BO">BOLIVIA</option>
            <option value="BA">BOSNIA AND HERZEGOVINA</option>
            <option value="BW">BOTSWANA</option>
            <option value="BV">BOUVET ISLAND</option>
            <option value="BR">BRAZIL</option>
            <option value="IO">BRITISH INDIAN OCEAN TERRITORY</option>
            <option value="BN">BRUNEI DARUSSALAM</option>
            <option value="BG">BULGARIA</option>
            <option value="BF">BURKINA FASO</option>
            <option value="BI">BURUNDI</option>
            <option value="KH">CAMBODIA</option>
            <option value="CM">CAMEROON</option>
            <option value="CA">CANADA</option>
            <option value="CV">CABO VERDE</option>
            <option value="KY">CAYMAN ISLANDS</option>
            <option value="CF">CENTRAL AFRICAN REPUBLIC</option>
            <option value="TD">CHAD</option>
            <option value="CL">CHILE</option>
            <option value="CN">CHINA</option>
            <option value="CX">CHRISTMAS ISLAND</option>
            <option value="CC">COCOS (KEELING) ISLANDS</option>
            <option value="CO">COLOMBIA</option>
            <option value="KM">COMOROS</option>
            <option value="CK">COOK ISLANDS</option>
            <option value="CR">COSTA RICA</option>
            <option value="HR">CROATIA</option>
            <option value="CY">CYPRUS</option>
            <option value="CZ">CZECHIA</option>
            <option value="DK">DENMARK</option>
            <option value="DJ">DJIBOUTI</option>
            <option value="DM">DOMINICA</option>
            <option value="DO">DOMINICAN REPUBLIC</option>
            <option value="EC">ECUADOR</option>
            <option value="EG">EGYPT</option>
            <option value="SV">EL SALVADOR</option>
            <option value="GQ">EQUATORIAL GUINEA</option>
            <option value="ER">ERITREA</option>
            <option value="EE">ESTONIA</option>
            <option value="ET">ETHIOPIA</option>
            <option value="FK">FALKLAND ISLANDS</option>
            <option value="FO">FAROE ISLANDS</option>
            <option value="FJ">FIJI</option>
            <option value="FI">FINLAND</option>
            <option value="FR">FRANCE</option>
            <option value="GF">FRENCH GUIANA</option>
            <option value="PF">FRENCH POLYNESIA</option>
            <option value="TF">FRENCH SOUTHERN TERRITORIES</option>
            <option value="GA">GABON</option>
            <option value="GM">GAMBIA</option>
            <option value="GE">GEORGIA</option>
            <option value="DE">GERMANY</option>
            <option value="GH">GHANA</option>
            <option value="GI">GIBRALTAR</option>
            <option value="GR">GREECE</option>
            <option value="GL">GREENLAND</option>
            <option value="GD">GRENADA</option>
            <option value="GP">GUADELOUPE</option>
            <option value="GU">GUAM</option>
            <option value="GT">GUATEMALA</option>
            <option value="GG">GUERNSEY</option>
            <option value="GN">GUINEA</option>
            <option value="GW">GUINEA-BISSAU</option>
            <option value="GY">GUYANA</option>
            <option value="HT">HAITI</option>
            <option value="HM">HEARD AND MCDONALD ISLANDS</option>
            <option value="VA">HOLY SEE (VATICAN CITY)</option>
            <option value="HN">HONDURAS</option>
            <option value="HK">HONG KONG</option>
            <option value="HU">HUNGARY</option>
            <option value="IS">ICELAND</option>
            <option value="IN">INDIA</option>
            <option value="ID">INDONESIA</option>
            <option value="IE">IRELAND</option>
            <option value="IM">ISLE OF MAN</option>
            <option value="IL">ISRAEL</option>
            <option value="IT">ITALY</option>
            <option value="JM">JAMAICA</option>
            <option value="JP">JAPAN</option>
            <option value="JE">JERSEY</option>
            <option value="JO">JORDAN</option>
            <option value="KZ">KAZAKHSTAN</option>
            <option value="KE">KENYA</option>
            <option value="KI">KIRIBATI</option>
            <option value="KR">KOREA, REPUBLIC OF</option>
            <option value="KW">KUWAIT</option>
            <option value="KG">KYRGYZSTAN</option>
            <option value="LA">LAOS</option>
            <option value="LV">LATVIA</option>
            <option value="LS">LESOTHO</option>
            <option value="LI">LICHTENSTEIN</option>
            <option value="LT">LITHUANIA</option>
            <option value="LU">LUXEMBOURG</option>
            <option value="MO">MACAU</option>
            <option value="MK">MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF</option>
            <option value="MG">MADAGASCAR</option>
            <option value="MW">MALAWI</option>
            <option value="MY">MALAYSIA</option>
            <option value="MV">MALDIVES</option>
            <option value="ML">MALI</option>
            <option value="MT">MALTA</option>
            <option value="MH">MARSHALL ISLANDS</option>
            <option value="MQ">MARTINIQUE</option>
            <option value="MR">MAURITANIA</option>
            <option value="MU">MAURITIUS</option>
            <option value="YT">MAYOTTE</option>
            <option value="MX">MEXICO</option>
            <option value="FM">MICRONESIA</option>
            <option value="MD">MOLDOVA</option>
            <option value="MC">MONACO</option>
            <option value="MN">MONGOLIA</option>
            <option value="ME">MONTENEGRO</option>
            <option value="MS">MONTSERRAT</option>
            <option value="MA">MOROCCO</option>
            <option value="MZ">MOZAMBIQUE</option>
            <option value="NA">NAMIBIA</option>
            <option value="NR">NAURU</option>
            <option value="NP">NEPAL</option>
            <option value="NL" selected="">NETHERLANDS</option>
            <option value="AN">NETHERLANDS ANTILLES</option>
            <option value="NC">NEW CALEDONIA</option>
            <option value="NZ">NEW ZEALAND</option>
            <option value="NI">NICARAGUA</option>
            <option value="NE">NIGER</option>
            <option value="NG">NIGERIA</option>
            <option value="NU">NIUE</option>
            <option value="NF">NORFOLK ISLAND</option>
            <option value="MP">NORTHERN MARIANA ISLANDS</option>
            <option value="NO">NORWAY</option>
            <option value="OM">OMAN</option>
            <option value="PK">PAKISTAN</option>
            <option value="PW">PALAU</option>
            <option value="PS">PALESTINIAN TERRITORY</option>
            <option value="PA">PANAMA</option>
            <option value="PG">PAPUA NEW GUINEA</option>
            <option value="PY">PARAGUAY</option>
            <option value="PE">PERU</option>
            <option value="PH">PHILIPPINES</option>
            <option value="PN">PITCAIRN</option>
            <option value="PL">POLAND</option>
            <option value="PT">PORTUGAL</option>
            <option value="PR">PUERTO RICO</option>
            <option value="QA">QATAR</option>
            <option value="RE">REUNION</option>
            <option value="RO">ROMANIA</option>
            <option value="RU">RUSSIAN FEDERATION</option>
            <option value="RW">RWANDA</option>
            <option value="BL">SAINT BARTHÉLEMY</option>
            <option value="SH">SAINT HELENA</option>
            <option value="KN">SAINT KITTS AND NEVIS</option>
            <option value="LC">SAINT LUCIA</option>
            <option value="MF">SAINT MARTIN</option>
            <option value="PM">SAINT PIERRE AND MIQUELON</option>
            <option value="VC">SAINT VINCENT AND THE GRENADINES</option>
            <option value="WS">SAMOA</option>
            <option value="SM">SAN MARINO</option>
            <option value="ST">SAO TOME AND PRINCIPE</option>
            <option value="SA">SAUDI ARABIA</option>
            <option value="SN">SENEGAL</option>
            <option value="RS">SERBIA</option>
            <option value="SC">SEYCHELLES</option>
            <option value="SL">SIERRA LEONE</option>
            <option value="SG">SINGAPORE</option>
            <option value="SK">SLOVAKIA</option>
            <option value="SI">SLOVENIA</option>
            <option value="SB">SOLOMON ISLANDS</option>
            <option value="ZA">SOUTH AFRICA</option>
            <option value="GS">SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS</option>
            <option value="ES">SPAIN</option>
            <option value="LK">SRI LANKA</option>
            <option value="SR">SURINAME</option>
            <option value="SJ">SVALBARD AND JAN MAYEN ISLANDS</option>
            <option value="SZ">ESWATINI</option>
            <option value="SE">SWEDEN</option>
            <option value="CH">SWITZERLAND</option>
            <option value="TW">TAIWAN</option>
            <option value="TJ">TAJIKISTAN</option>
            <option value="TZ">TANZANIA</option>
            <option value="TH">THAILAND</option>
            <option value="TL">TIMOR-LESTE</option>
            <option value="TG">TOGO</option>
            <option value="TK">TOKELAU</option>
            <option value="TO">TONGA</option>
            <option value="TT">TRINIDAD AND TOBAGO</option>
            <option value="TN">TUNISIA</option>
            <option value="TR">TURKEY</option>
            <option value="TM">TURKMENISTAN</option>
            <option value="TC">TURKS AND CAICOS ISLANDS</option>
            <option value="TV">TUVALU</option>
            <option value="UG">UGANDA</option>
            <option value="UA">UKRAINE</option>
            <option value="AE">UNITED ARAB EMIRATES</option>
            <option value="GB">UNITED KINGDOM (GREAT BRITAIN)</option>
            <option value="US">UNITED STATES OF AMERICA</option>
            <option value="UM">UNITED STATES MINOR ISLANDS</option>
            <option value="UY">URUGUAY</option>
            <option value="UZ">UZBEKISTAN</option>
            <option value="VU">VANUATU</option>
            <option value="VN">VIET NAM</option>
            <option value="VG">VIRGIN ISLANDS (BRITISH)</option>
            <option value="VI">VIRGIN ISLANDS (USA)</option>
            <option value="WF">WALLIS AND FUTUNA</option>
            <option value="EH">WESTERN SAHARA</option>
            <option value="YE">YEMEN</option>
            <option value="ZM">ZAMBIA</option>
          </select>
        </p>
      </div>
    </div>
    <div id="divxsell_0" class="divxsell">
      <p class="required">
        <input type="checkbox" name="xsell_checkbox_0" id="xsell_checkbox_0" class="inputCheckbox xsellCheckbox" checked="checked">
        <label class="labelCheckbox" for="xsell_checkbox_0"> placeholder xsell text </label>
      </p>
    </div>
    <div id="divxsell_1" class="divxsell">
      <p class="required">
        <input type="checkbox" name="xsell_checkbox_1" id="xsell_checkbox_1" class="inputCheckbox xsellCheckbox" checked="checked">
        <label class="labelCheckbox" for="xsell_checkbox_1"> placeholder xsell text </label>
      </p>
    </div>
    <div id="desc" class="desc">
      <p class="descriptor">En complétant cette transaction vous reconnaissez avoir 18 ans ou plus et avoir lu et accepté nos
        <a href="javascript:void(0);" onclick="javascript:window.open('http://coquinsdefrance.com/terms');" class="desc_link">Conditions d’Utilisation</a> ainsi que notre
        <a href="javascript:void(0);" onclick="javascript:window.open('http://coquinsdefrance.com/privacy');" class="desc_link">Politique de Confidentialité</a>. </p>
    </div>
    <div id="divsubmit">
      <p align="center">
        <input type="BUTTON" id="submitButton" class="push_button green" value="OBTENEZ VOTRE ACCÈS GRATUIT!">
      </p>
    </div>
    <div class="footer">&nbsp;</div>
  </div>
</form>

Text Content

Confirmez que vous avez plus de 18 ans - Montant de la transaction: 0€ !

Fermer

18+ Vérification de votre majorité


ACHAT SÉCURISÉ



Email:

Prénom:

Nom du titulaire de la Carte:

Numéro de carte:

CVV2:

Date d´expiration: MM 01 - Jan 02 - Feb 03 - Mar 04 - Apr 05 - May 06 - Jun 07 -
Jul 08 - Aug 09 - Sep 10 - Oct 11 - Nov 12 - Dec YYYY 2023 2024 2025 2026 2027
2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042

Code Postal:

Pays: Please select your country UNITED STATES OF AMERICA AUSTRALIA CANADA
FRANCE GERMANY JAPAN UNITED KINGDOM (GREAT BRITAIN) ------------ AFGHANISTAN
ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA
ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS
BAHRAIN BANGLADESH BARBADOS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA
AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY
BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CABO
VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND
COCOS (KEELING) ISLANDS COLOMBIA COMOROS COOK ISLANDS COSTA RICA CROATIA CYPRUS
CZECHIA DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR
EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS FAROE ISLANDS FIJI
FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON
GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM
GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD AND MCDONALD ISLANDS
HOLY SEE (VATICAN CITY) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA
IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA
KIRIBATI KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAOS LATVIA LESOTHO LICHTENSTEIN
LITHUANIA LUXEMBOURG MACAU MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR
MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA
MAURITIUS MAYOTTE MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO
MONTSERRAT MOROCCO MOZAMBIQUE NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS
ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND
NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY PANAMA
PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO
QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHÉLEMY SAINT HELENA
SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN SAINT PIERRE AND MIQUELON SAINT
VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA
SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON
ISLANDS SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI
LANKA SURINAME SVALBARD AND JAN MAYEN ISLANDS ESWATINI SWEDEN SWITZERLAND TAIWAN
TAJIKISTAN TANZANIA THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO
TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE
UNITED ARAB EMIRATES UNITED KINGDOM (GREAT BRITAIN) UNITED STATES OF AMERICA
UNITED STATES MINOR ISLANDS URUGUAY UZBEKISTAN VANUATU VIET NAM VIRGIN ISLANDS
(BRITISH) VIRGIN ISLANDS (USA) WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA

placeholder xsell text

placeholder xsell text

En complétant cette transaction vous reconnaissez avoir 18 ans ou plus et avoir
lu et accepté nos Conditions d’Utilisation ainsi que notre Politique de
Confidentialité.



 



@@ROCKETPAY-TEXT@@

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