www.app.mijnuitvaartgeregeld.com
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2a02:5b40:4:200::6
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Submitted URL: https://www.app.mijnuitvaartgeregeld.com/
Effective URL: https://www.app.mijnuitvaartgeregeld.com/sign-up
Submission: On July 06 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://www.app.mijnuitvaartgeregeld.com/sign-up
Submission: On July 06 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="row">
<div class="col-md-6 pr-lg-4">
<div class="form-group"><select id="gender" name="gender" required="required" class="form-control">
<option disabled="disabled" hidden="hidden" value="">Geslacht *</option>
<option value="M">Man</option>
<option value="V">Vrouw</option>
<option>Anders</option>
</select></div>
<div class="form-group"><input id="firstName" type="text" name="firstName" placeholder="Voornaam *" required="required" autofocus="autofocus" class="form-control"></div>
<div class="form-group"><input id="lastName" type="text" name="lastName" placeholder="Achternaam *" required="required" class="form-control"></div>
<div class="form-group"><input id="phoneNumber" type="text" name="phoneNumber" placeholder="Telefoon nr. *" required="required" class="form-control"></div>
<div class="form-group">
<div class="date-dropdowns"><!----> <!----> <!----> <select name="year" id="year" class="form-control date-selector">
<option value="">Geboortejaar</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
<option value="1910">1910</option>
<option value="1909">1909</option>
<option value="1908">1908</option>
<option value="1907">1907</option>
<option value="1906">1906</option>
<option value="1905">1905</option>
<option value="1904">1904</option>
<option value="1903">1903</option>
<option value="1902">1902</option>
<option value="1901">1901</option>
<option value="1900">1900</option>
</select> <select name="month" id="month" class="form-control date-selector">
<option value="">Maand</option>
<option value="1">Januari</option>
<option value="2">Februari</option>
<option value="3">Maart</option>
<option value="4">April</option>
<option value="5">Mei</option>
<option value="6">Juni</option>
<option value="7">Juli</option>
<option value="8">Augustus</option>
<option value="9">September</option>
<option value="10">October</option>
<option value="11">November</option>
<option value="12">December</option>
</select> <select name="day" id="day" class="form-control date-selector">
<option value="">Dag</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select> <!----> <!----> <!----></div>
</div>
</div>
<div class="col-md-6 pl-lg-4">
<div class="form-group"><input id="city" type="text" name="city" placeholder="Woonplaats *" required="required" class="form-control"></div>
<div class="form-group"><select id="country" name="country" class="form-control">
<option disabled="disabled" hidden="hidden" value="">Land</option>
<option>Nederland</option>
<option>België</option>
<option>Andere</option>
</select></div>
<div class="form-group"><input id="email" type="text" name="email" placeholder="E-mailadres *" required="required" class="form-control"></div>
<div class="form-group"><input id="password" type="password" name="password" placeholder="Wachtwoord *" required="required" class="form-control"></div>
<div class="form-group">
<div class="form-group"><input id="password_confirmation" type="password" name="password_confirmation" placeholder="Herhaal Wachtwoord *" required="required" class="form-control"> <small class="password-help form-text text-muted">Het
wachtwoord moet minstens een hoofdletter, een kleine letter, een cijfer en één van deze karakters bevatten: !$&#()@=<>+%</small></div>
</div>
</div>
<div class="col-12 col-lg-6 offset-0 offset-lg-6">
<div class="form-group ml-0 ml-lg-2">
<div class="form-check"><input type="checkbox" id="privacyPolicy"> <label for="privacyPolicy" class="privacy-ack-label">Ik heb het
<a target="_blank" href="https://www.mijnuitvaartgeregeld.com/privacy-policy/" class="default-link">privacy beleid</a>, de <a target="_blank" href="https://www.mijnuitvaartgeregeld.com/disclaimer/" class="default-link">disclaimer</a> en
de <a target="_blank" href="https://www.mijnuitvaartgeregeld.com/gebruiksovereenkomst/" class="default-link">gebruiksovereenkomst</a> gelezen en ga hiermee akkoord.</label></div>
</div>
</div>
</div>
<div class="text-right"><button type="submit" class="btn form-submit mt-5"> Volgende stap <img src="https://www.app.mijnuitvaartgeregeld.com/img/button-next-icon.png"></button></div>
</form>Text Content
* Registreren * Inloggen VUL HIER JE PERSOONLIJKE GEGEVENS IN Registreer je uitvaartwensen online, zodat ze na je overlijden bij je naasten terechtkomen én daadwerkelijk gerealiseerd worden. Als je tijdens het invullen terug wilt gaan naar de website, dan kun je op het logo linksboven drukken. Als je daarna terug inlogt, zijn je ingevulde gegevens hier bewaard. Geslacht * Man Vrouw Anders Geboortejaar20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 MaandJanuariFebruariMaartAprilMeiJuniJuliAugustusSeptemberOctoberNovemberDecember Dag12345678910111213141516171819202122232425262728293031 Land Nederland België Andere Het wachtwoord moet minstens een hoofdletter, een kleine letter, een cijfer en één van deze karakters bevatten: !$&#()@=<>+% Ik heb het privacy beleid, de disclaimer en de gebruiksovereenkomst gelezen en ga hiermee akkoord. Volgende stap Hoe het werkt - Onze missie - FAQ - Privacy Policy - Gebruiksovereenkomst - Disclaimer - Webdesign Creatic