www.forms.eztel.com.au
Open in
urlscan Pro
203.4.149.23
Public Scan
URL:
https://www.forms.eztel.com.au/
Submission: On August 31 via api from US — Scanned from AU
Submission: On August 31 via api from US — Scanned from AU
Form analysis 1 forms found in the DOM
POST submit_form.php
<form class="form-register" id="form-register" action="submit_form.php" method="post">
<div id="form-total" role="application" class="wizard clearfix">
<div class="steps clearfix">
<ul role="tablist">
<li role="tab" aria-disabled="false" class="first current" aria-selected="true"><a id="form-total-t-0" href="#form-total-h-0" aria-controls="form-total-p-0"><span class="current-info audible"> </span><div class="title">
<p class="step-icon"><span>1</span></p>
<span class="step-text">Customer Info</span>
</div></a></li>
<li role="tab" aria-disabled="false"><a id="form-total-t-1" href="#form-total-h-1" aria-controls="form-total-p-1"><div class="title">
<p class="step-icon"><span>2</span></p>
<span class="step-text">Order a Plan</span>
</div></a></li>
<li role="tab" aria-disabled="false" class="last"><a id="form-total-t-2" href="#form-total-h-2" aria-controls="form-total-p-2"><div class="title">
<p class="step-icon"><span>3</span></p>
<span class="step-text">Confirm</span>
</div></a></li>
</ul>
</div>
<div class="content clearfix">
<!-- SECTION 1 -->
<h2 id="form-total-h-0" tabindex="-1" class="title current">
<p class="step-icon"><span>1</span></p>
<span class="step-text">Customer Info</span>
</h2>
<section id="form-total-p-0" role="tabpanel" aria-labelledby="form-total-h-0" class="body current" aria-hidden="false">
<div class="inner">
<div class="form-heading">
<h3>Customer Info</h3>
<span>1/3</span>
</div>
<div class="form-row">
<div class="form-holder">
<label class="form-row-inner">
<select class="form-control" id="prefix" name="prefix" required="">
<option value="" disabled="" selected="">Select Prefix</option>
<option value="Mr">Mr.</option>
<option value="Mrs">Mrs.</option>
<option value="Ms">Ms.</option>
<option value="Miss">Miss</option>
</select>
<span class="label">Prefix</span>
</label>
</div>
<div class="form-holder">
<label class="form-row-inner">
<input type="text" class="form-control" id="first_name" name="first_name" required="">
<span class="label">First Name</span>
</label>
</div>
<div class="form-holder">
<label class="form-row-inner">
<input type="text" class="form-control" id="last_name" name="last_name" required="">
<span class="label">Last Name</span>
</label>
</div>
</div>
<div class="form-row">
<div class="form-holder input-container">
<label class="form-row-inner">
<input type="email" name="email_address" id="email_address" class="form-control" required="">
<span class="label">Email Address</span>
<span id="email_address_error" class="error-message"></span>
</label>
</div>
<div class="form-holder input-container">
<label class="form-row-inner">
<input type="tel" class="form-control" id="contact_number" name="contact_number" required="">
<span class="label">Mobile Number (e.g. 04XX XXX XXX)</span>
<span id="contact_number_error" class="error-message"></span>
</label>
</div>
</div>
<div class="form-row">
<div class="form-holder form-holder-2">
<label class="form-row-inner">
<input type="text" class="form-control" id="address" name="address" required="">
<span class="label">Address</span>
</label>
</div>
</div>
<div class="form-row">
<div class="form-holder">
<label class="form-row-inner">
<input type="text" class="form-control" id="city" name="city" required="">
<span class="label">Suburb</span>
</label>
</div>
<div class="form-holder">
<label class="form-row-inner">
<input type="text" class="form-control" id="state_province" name="state_province" required="">
<span class="label">State</span>
</label>
</div>
<div class="form-holder">
<label class="form-row-inner">
<input type="text" class="form-control" id="zip_postal_code" name="zip_postal_code" required="">
<span class="label">Post Code</span>
</label>
</div>
</div>
<div class="form-row input-container">
<div class="form-holder">
<label class="form-row-inner">
<input type="text" class="form-control hasDatepicker" id="dob" name="dob" required=""><button type="button" class="ui-datepicker-trigger"><i class="zmdi zmdi-chevron-down"></i></button>
<span class="label">Date of Birth (DD/MM/YYYY)</span>
<span id="dob_error" class="error-message"></span>
</label>
</div>
<div class="form-holder-3">
<div class="radio-group">
<input type="radio" id="customer_type_residential" name="customer_type" value="Residential" checked="" required="">
<label for="customer_type_residential">Residential</label>
</div>
<div class="radio-group">
<input type="radio" id="business" name="customer_type" value="Business" required="">
<label for="business">Business</label>
</div>
</div>
</div>
<!-- Business Fields (Initially Hidden) -->
<div id="business-fields" class="hidden" style="display: none;">
<div class="form-row">
<div class="form-holder">
<label class="form-row-inner">
<input type="text" class="form-control" id="company_name" name="company_name">
<span class="label">Company Name</span>
</label>
</div>
<div class="form-holder input-container">
<label class="form-row-inner">
<input type="text" class="form-control" id="abn_acn" name="abn_acn">
<span class="label">ABN/ACN</span>
<span id="abn_acn_error" class="error-message"></span>
</label>
</div>
</div>
</div>
</div>
</section>
<!-- SECTION 2 -->
<h2 id="form-total-h-1" tabindex="-1" class="title">
<p class="step-icon"><span>2</span></p>
<span class="step-text">Order a Plan</span>
</h2>
<section id="form-total-p-1" role="tabpanel" aria-labelledby="form-total-h-1" class="body" aria-hidden="true" style="display: none;">
<div class="inner">
<div class="form-heading">
<h3 id="plan-title">Order a Plan</h3>
<span>2/3</span>
</div>
<div class="form-row">
<div class="form-holder form-holder-2">
<div id="plan-description-2">
<!-- Description will be populated by JavaScript based on customer type -->
</div>
<select id="plan" name="plan_name" data-price="" class="form-control" required="">
<option value="" disabled="" selected="">Select EzNBN Plan</option>
<option value="25/10Mbps" data-price="65.00" data-description="EzNBN 25/10Mbps">25/10Mbps</option>
<option value="50/20Mbps" data-price="85.00" data-description="EzNBN 50/20Mbps">50/20Mbps</option>
<option value="100/20Mbps" data-price="95.00" data-description="EzNBN 100/20Mbps">100/20Mbps</option>
<option value="100/40Mbps" data-price="99.00" data-description="EzNBN 100/40Mbps">100/40Mbps</option>
<option value="250/25Mbps" data-price="109.00" data-description="EzNBN 250/25Mbps">250/25Mbps</option>
<option value="1000/50Mbps" data-price="129.00" data-description="EzNBN 1000/50Mbps">1000/50Mbps</option>
</select>
<input type="hidden" id="plan-hidden" name="plan_id">
<input type="hidden" id="plan-description-hidden" name="plan_description">
<input type="hidden" id="plan-price-hidden" name="plan_price">
<span class="select-btn">
<i class="zmdi zmdi-chevron-down"></i>
</span>
</div>
</div>
<div class="form-row">
<div class="form-holder">
<label for="phone-plan" class="special-label special-label-2">EzPhone Plans:</label>
<select id="phone-plan" name="phone_plan_name" data-price="">
<option value="" disabled="" selected="">Select EzPhone Plan</option>
<option value="No EzPhone: EzNBN Only">No EzPhone: EzNBN Only</option>
<option value="PAYG" data-price="0.00" data-description="Pay As You Go plan">PAYG</option>
<option value="$10 per line" data-price="10.00" data-description="Local & National Calls Include">$10 per line</option>
<option value="$20 per line" data-price="20.00" data-description="Local, National, 1300 & Mobile Calls Includes">$20 per line</option>
</select>
<input type="hidden" id="phone-plan-hidden" name="phone_plan_id">
<input type="hidden" id="phone-plan-description-hidden" name="phone_plan_description">
<input type="hidden" id="phone-plan-price-hidden" name="phone_plan_price">
<span class="select-btn">
<i class="zmdi zmdi-chevron-down"></i>
</span>
</div>
</div>
</div>
</section>
<!-- SECTION 3 -->
<h2 id="form-total-h-2" tabindex="-1" class="title">
<p class="step-icon"><span>3</span></p>
<span class="step-text">Confirm</span>
</h2>
<section id="form-total-p-2" role="tabpanel" aria-labelledby="form-total-h-2" class="body" aria-hidden="true" style="display: none;">
<div class="inner">
<div class="form-heading">
<h3>Confirm Details</h3>
<span>3/3</span>
</div>
<div class="table-responsive">
<table class="table">
<tbody>
<tr class="space-row">
<th>Full Name:</th>
<td id="fullname-val"></td>
</tr>
<tr class="space-row">
<th>Email Address:</th>
<td id="email-val"></td>
</tr>
<tr class="space-row">
<th>Contact Number:</th>
<td id="contact-val"></td>
</tr>
<tr class="space-row">
<th>Address:</th>
<td id="address-val"></td>
</tr>
<tr class="space-row">
<th>Date of Birth:</th>
<td id="dob-val"></td>
</tr>
<tr class="space-row">
<th>Customer Type:</th>
<td id="nbn-val"></td>
</tr>
<tr class="space-row">
<th>Broadband Plan:</th>
<td id="plan-val"></td>
</tr>
<tr class="space-row phone-row">
<th>Phone Plan:</th>
<td id="phone-plan-val"></td>
</tr>
<tr class="space-row company-row" style="display: none;">
<th>Company Name:</th>
<td id="company-name-val"></td>
</tr>
<tr class="space-row abn-acn-row" style="display: none;">
<th>ABN/ACN:</th>
<td id="abn-acn-val"></td>
</tr>
</tbody>
</table>
</div>
<hr>
<div class="form-row">
<label class="form-row-inner">
<input type="checkbox" id="consent" name="consent" required="">
<span class="label"> I agree to <strong>EzTel's</strong> <a href="https://eztel.com.au/terms-conditions/" target="_blank" class="terms-link">terms and conditions</a>. </span>
</label>
</div>
</div>
</section>
</div>
<div class="actions clearfix">
<ul role="menu" aria-label="Pagination">
<li class="disabled" aria-disabled="true"><a href="#previous" role="menuitem">Back</a></li>
<li aria-hidden="false" aria-disabled="false"><a href="#next" role="menuitem">Next</a></li>
<li aria-hidden="true" style="display: none;"><a href="#finish" role="menuitem">Confirm</a></li>
</ul>
</div>
</div>
</form>Text Content
SERVICE APPLICATION FORM * 1 Customer Info * 2 Order a Plan * 3 Confirm 1 CUSTOMER INFO CUSTOMER INFO 1/3 Select Prefix Mr. Mrs. Ms. Miss Prefix First Name Last Name Email Address Mobile Number (e.g. 04XX XXX XXX) Address Suburb State Post Code Date of Birth (DD/MM/YYYY) Residential Business Company Name ABN/ACN 2 ORDER A PLAN ORDER A PLAN 2/3 Select EzNBN Plan25/10Mbps50/20Mbps100/20Mbps100/40Mbps250/25Mbps1000/50Mbps EzPhone Plans: Select EzPhone PlanNo EzPhone: EzNBN OnlyPAYG$10 per line$20 per line 3 CONFIRM CONFIRM DETAILS 3/3 Full Name: Email Address: Contact Number: Address: Date of Birth: Customer Type: Broadband Plan: Phone Plan: Company Name: ABN/ACN: -------------------------------------------------------------------------------- I agree to EzTel's terms and conditions. * Back * Next * Confirm