upstream.gov.edmonton.ab.ca Open in urlscan Pro
162.106.2.12  Public Scan

Form analysis
1 forms found in the DOM

POST /Home/Chat

<form action="/Home/Chat" autocomplete="off" class="form-horizontal" id="chatrequestform" method="post" role="form" novalidate="novalidate">
  <div class="modal show" id="chat-req-modal">
    <div class="modal-content">
      <div class="modal-header">
        <button type="button" class="close hidden" aria-hidden="true" data-dismiss="window">×</button>
        <h4 aria-level="1" class="modal-title" role="heading">Please enter some information</h4>
      </div>
      <div class="modal-body">
        <div class="form-group ">
          <label class="col-xs-12 col-sm-2 control-label" for="ContactName">Name</label>
          <div class="col-xs-12 col-sm-10">
            <input autocomplete="name" class="form-control" id="ContactName" name="ContactName" placeholder="Name" type="text" value="">
            <span class="field-validation-valid help-block" data-valmsg-for="ContactName" data-valmsg-replace="true"></span>
          </div>
        </div>
        <div class="form-group ">
          <label class="col-xs-12 col-sm-2 control-label" for="Email">Email</label>
          <div class="col-xs-12 col-sm-10">
            <input autocomplete="email" class="form-control" data-val="true" data-val-regex="The email provided is not a valid email address" data-val-regex-pattern="^[^@]+@([^@\.]+\.)+[^@\.]+$" id="Email" name="Email" placeholder="Email" type="text"
              value="">
            <span class="field-validation-valid help-block" data-valmsg-for="Email" data-valmsg-replace="true"></span>
          </div>
        </div>
        <div class="form-group ">
          <label class="col-xs-12 col-sm-2 control-label" for="CustomerId">Account #</label>
          <div class="col-xs-12 col-sm-10">
            <input class="form-control" id="CustomerId" name="CustomerId" placeholder="Account #" type="text" value="">
            <span class="field-validation-valid help-block" data-valmsg-for="CustomerId" data-valmsg-replace="true"></span>
          </div>
        </div>
        <div class="form-group ">
          <label class="col-xs-12 col-sm-2 control-label" for="Phone">Phone #</label>
          <div class="col-xs-12 col-sm-10">
            <input autocomplete="tel" class="form-control" id="Phone" name="Phone" placeholder="Phone #" type="text" value="">
            <span class="field-validation-valid help-block" data-valmsg-for="Phone" data-valmsg-replace="true"></span>
          </div>
        </div>
        <div class="form-group ">
          <label class="col-xs-12 col-sm-2 control-label" for="Message">Message</label>
          <div class="col-xs-12 col-sm-10">
            <input class="form-control" id="Message" name="Message" placeholder="Message" type="text" value="">
            <span class="field-validation-valid help-block" data-valmsg-for="Message" data-valmsg-replace="true"></span>
          </div>
        </div>
        <div class="form-group">
          <label class="col-xs-12 col-sm-2 control-label" for="UserLanguage">Language</label>
          <div class="col-xs-12 col-sm-10">
            <select autocomplete="language" class="form-control" id="UserLanguage" name="UserLanguage">
              <option value="en">English</option>
              <option value="fr">French</option>
              <option value="es">Spanish</option>
              <option value="de">German </option>
              <option value="pt">Portuguese</option>
              <option value="it">Italian</option>
              <option value="ru">Russian</option>
              <option value="pl">Polish</option>
              <option value="zh">Chinese</option>
            </select>
          </div>
        </div>
        <input id="Parameters_CustomKey_" name="Parameters[CustomKey]" type="hidden" value="CustomValue">
        <input id="Parameters_TimeZoneOffset_" name="Parameters[TimeZoneOffset]" type="hidden" value="">
        <input id="Parameters_DocumentReferrer_" name="Parameters[DocumentReferrer]" type="hidden" value="">
        <div class="form-group">
          <label class="col-xs-12 col-sm-2 control-label" for="Reason">Reason</label>
          <div class="col-xs-12 col-sm-10">
            <select class="form-control" id="Reason" name="Reason">
              <option></option>
            </select>
            <span class="field-validation-valid help-block" data-valmsg-for="Reason" data-valmsg-replace="true"></span>
          </div>
        </div>
      </div>
      <div class="modal-footer">
        <button type="button" class="btn btn-default btn-close hidden" data-dismiss="window">Close</button>
        <button type="submit" class="btn btn-primary letschat">Let's Chat!</button>
      </div>
    </div>
  </div>
</form>

Text Content

×

PLEASE ENTER SOME INFORMATION

Name

Email

Account #

Phone #

Message

Language
English French Spanish German Portuguese Italian Russian Polish Chinese
Reason

Close Let's Chat!