partner.midenity.com Open in urlscan Pro
54.197.234.166 Public Scan

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Submitted URL:
http://midenity.com/
Effective URL:
https://partner.midenity.com/login
Submission Tags: tranco_l324
Submission: On April 03 via api (April 3rd 2024, 3:06:54 am UTC) from DE — Scanned from DE

Form analysis
4 forms found in the DOM

POST https://partner.midenity.com/attempt-login

<form method="POST" action="https://partner.midenity.com/attempt-login" class="form-guest">
  <input type="hidden" name="_token" value="s3dkLE6ehFKBqkNeqqHTPpl6xbxaVDs6L8ksRGbB">
  <div class="form-group">
    <label for="loginEmail">Username</label>
    <input type="text" class="form-control" id="loginEmail" name="login" aria-describedby="loginEmail" value="" required="">
  </div>
  <div class="form-group">
    <label for="loginPassword">Password</label>
    <input type="password" class="form-control" name="password" id="loginPassword" required="">
  </div>
  <div class="col px-0 my-3 btn-group btn-group-toggle" data-toggle="buttons">
    <label class="btn btn-outline-primary w-50 active">
      <input type="radio" name="loginType" id="aff" autocomplete="off" value="aff" checked=""> Affiliate </label>
    <label class="btn btn-outline-primary w-50">
      <input type="radio" name="loginType" id="adv" autocomplete="off" value="adv"> Advertiser </label>
  </div>
  <div class="row text-center">
    <div class="col">
      <button type="submit" class="my-4 btn btn-primary btn-lg">Login</button>
      <hr class="my-3">
      <a id="forgotPassword" href="#">Forgot Password?</a>
    </div>
  </div>
  <hr>
  <div class="row text-center mt-4">
    <div class="col-12 text-center mb-2">
      <a href="#" data-toggle="modal" data-target="#advertiserApplication">Advertiser Application</a>
    </div>
    <!-- loop through custom content -->
  </div>
</form>

POST https://partner.midenity.com/forgot-password

<form method="POST" action="https://partner.midenity.com/forgot-password">
  <input type="hidden" name="_token" value="s3dkLE6ehFKBqkNeqqHTPpl6xbxaVDs6L8ksRGbB">
  <div class="form-group">
    <label for="passwordUsername">Username</label>
    <input type="text" class="form-control" id="passwordUsername" name="passwordUsername" aria-describedby="passwordUsername">
  </div>
  <div class="form-group">
    <label for="passwordEmail">Email Address</label>
    <input type="email" class="form-control" id="passwordEmail" name="passwordEmail" aria-describedby="passwordEmail">
  </div>
  <div class="col px-0 my-3 btn-group btn-group-toggle" data-toggle="buttons">
    <label class="btn btn-outline-primary w-50 active">
      <input type="radio" name="resetType" id="aff" value="aff" autocomplete="off" checked=""> Affiliate </label>
    <label class="btn btn-outline-primary w-50">
      <input type="radio" name="resetType" id="adv" value="adv" autocomplete="off"> Advertiser </label>
  </div>
  <div class="row">
    <div class="col">
      <a href="#" data-dismiss="modal" id="forgotPasswordCancel" class="mt-4 btn btn-light btn-lg">Cancel</a>
    </div>
    <div class="col text-right">
      <button id="forgotPasswordSubmit" type="submit" class="mt-4 btn btn-primary btn-lg">Submit</button>
    </div>
  </div>
  <div class="row mt-3">
    <div class="col">
      <small class="muted"></small>
    </div>
  </div>
</form>

POST https://partner.midenity.com/adv-application-submit

<form class="application-form" method="post" action="https://partner.midenity.com/adv-application-submit">
  <div class="row">
    <div class="application-form-left col-12 col-lg-6 px-lg-4">
      <div class="row">
        <div class="col">
          <h5>Contact Information</h5>
        </div>
      </div>
      <input type="hidden" name="_token" value="s3dkLE6ehFKBqkNeqqHTPpl6xbxaVDs6L8ksRGbB">
      <div class="form-group">
        <label for="companyname" class="form-required">Company</label>
        <input type="text" class="form-control form-control-sm " id="companyname" name="company" value="" required="">
      </div>
      <div class="form-group">
        <label for="firstname" class="form-required">First Name</label>
        <input type="text" class="form-control form-control-sm " id="firstname" name="fname" value="" required="">
      </div>
      <div class="form-group">
        <label for="lastname" class="form-required">Last Name</label>
        <input type="text" class="form-control form-control-sm " id="lastname" name="lname" value="" required="">
      </div>
      <div class="form-group">
        <label for="adv-address1" class="form-required">Address 1</label>
        <input type="text" class="form-control form-control-sm " id="adv-address1" name="address1" value="" maxlength="100" required="">
      </div>
      <div class="form-group">
        <label for="adv-apt" class="">Apt/Suite</label>
        <input type="text" class="form-control form-control-sm " id="adv-apt" name="address2" value="" maxlength="100">
      </div>
      <div class="form-group">
        <label for="adv-city" class="form-required">City</label>
        <input type="text" class="form-control form-control-sm " id="adv-city" name="city" value="" required="">
      </div>
      <div class="row">
        <div class="col-12 col-sm-7">
          <div class="form-group">
            <label for="advstate_select" class="form-required">State/Territory</label>
            <input type="text" class="form-control form-control-sm " id="advstate_text" value="" style="display:none">
            <select id="advstate_select" class="form-control form-control-sm " name="state" required="">
              <option value="AL">Alabama</option>
              <option value="AK">Alaska</option>
              <option value="AZ">Arizona</option>
              <option value="AR">Arkansas</option>
              <option value="CA">California</option>
              <option value="CO">Colorado</option>
              <option value="CT">Connecticut</option>
              <option value="DE">Delaware</option>
              <option value="DC">District Of Columbia</option>
              <option value="FL">Florida</option>
              <option value="GA">Georgia</option>
              <option value="HI">Hawaii</option>
              <option value="ID">Idaho</option>
              <option value="IL">Illinois</option>
              <option value="IN">Indiana</option>
              <option value="IA">Iowa</option>
              <option value="KS">Kansas</option>
              <option value="KY">Kentucky</option>
              <option value="LA">Louisiana</option>
              <option value="ME">Maine</option>
              <option value="MD">Maryland</option>
              <option value="MA">Massachusetts</option>
              <option value="MI">Michigan</option>
              <option value="MN">Minnesota</option>
              <option value="MS">Mississippi</option>
              <option value="MO">Missouri</option>
              <option value="MT">Montana</option>
              <option value="NE">Nebraska</option>
              <option value="NV">Nevada</option>
              <option value="NH">New Hampshire</option>
              <option value="NJ">New Jersey</option>
              <option value="NM">New Mexico</option>
              <option value="NY">New York</option>
              <option value="NC">North Carolina</option>
              <option value="ND">North Dakota</option>
              <option value="OH">Ohio</option>
              <option value="OK">Oklahoma</option>
              <option value="OR">Oregon</option>
              <option value="PA">Pennsylvania</option>
              <option value="RI">Rhode Island</option>
              <option value="SC">South Carolina</option>
              <option value="SD">South Dakota</option>
              <option value="TN">Tennessee</option>
              <option value="TX">Texas</option>
              <option value="UT">Utah</option>
              <option value="VT">Vermont</option>
              <option value="VA">Virginia</option>
              <option value="WA">Washington</option>
              <option value="WV">West Virginia</option>
              <option value="WI">Wisconsin</option>
              <option value="WY">Wyoming</option>
            </select>
          </div>
        </div>
        <div class="col-12 col-sm-5">
          <div class="form-group">
            <label for="adv-zip" class="form-required">Zip/Postal</label>
            <input type="text" class="form-control form-control-sm " id="adv-zip" name="zip" value="" required="">
          </div>
        </div>
      </div>
      <div class="form-group">
        <label for="advcountry" class="form-required">Country</label>
        <select id="advcountry" class="form-control form-control-sm " name="country" required="">
          <option value="AD"> Andorra </option>
          <option value="AE"> United Arab Emirates </option>
          <option value="AF"> Afghanistan </option>
          <option value="AG"> Antigua And Barbuda </option>
          <option value="AI"> Anguilla </option>
          <option value="AL"> Albania </option>
          <option value="AM"> Armenia </option>
          <option value="AN"> Netherlands Antilles </option>
          <option value="AO"> Angola </option>
          <option value="AP"> Non-spec Asia Pas Location </option>
          <option value="AR"> Argentina </option>
          <option value="AS"> American Samoa </option>
          <option value="AT"> Austria </option>
          <option value="AU"> Australia </option>
          <option value="AW"> Aruba </option>
          <option value="AX"> &amp;#197;land Islands </option>
          <option value="AZ"> Azerbaijan </option>
          <option value="BA"> Bosnia And Herzegowina </option>
          <option value="BB"> Barbados </option>
          <option value="BD"> Bangladesh </option>
          <option value="BE"> Belgium </option>
          <option value="BF"> Burkina Faso </option>
          <option value="BG"> Bulgaria </option>
          <option value="BH"> Bahrain </option>
          <option value="BI"> Burundi </option>
          <option value="BJ"> Benin </option>
          <option value="BM"> Bermuda </option>
          <option value="BN"> Brunei Darussalam </option>
          <option value="BO"> Bolivia </option>
          <option value="BR"> Brazil </option>
          <option value="BS"> Bahamas </option>
          <option value="BT"> Bhutan </option>
          <option value="BW"> Botswana </option>
          <option value="BY"> Belarus </option>
          <option value="BZ"> Belize </option>
          <option value="CA"> Canada </option>
          <option value="CD"> Congo The Democratic Republic Of The </option>
          <option value="CF"> Central African Republic </option>
          <option value="CG"> Congo </option>
          <option value="CH"> Switzerland </option>
          <option value="CK"> Cook Islands </option>
          <option value="CL"> Chile </option>
          <option value="CM"> Cameroon </option>
          <option value="CN"> China </option>
          <option value="CO"> Colombia </option>
          <option value="CR"> Costa Rica </option>
          <option value="CS"> Serbia And Montenegro </option>
          <option value="CU"> Cuba </option>
          <option value="CV"> Cape Verde </option>
          <option value="CY"> Cyprus </option>
          <option value="CZ"> Czech Republic </option>
          <option value="DE"> Germany </option>
          <option value="DJ"> Djibouti </option>
          <option value="DK"> Denmark </option>
          <option value="DO"> Dominican Republic </option>
          <option value="DZ"> Algeria </option>
          <option value="EC"> Ecuador </option>
          <option value="EE"> Estonia </option>
          <option value="EG"> Egypt </option>
          <option value="ER"> Eritrea </option>
          <option value="ES"> Spain </option>
          <option value="ET"> Ethiopia </option>
          <option value="EU"> European Union </option>
          <option value="FI"> Finland </option>
          <option value="FJ"> Fiji </option>
          <option value="FM"> Micronesia Federated States Of </option>
          <option value="FO"> Faroe Islands </option>
          <option value="FR"> France </option>
          <option value="GA"> Gabon </option>
          <option value="UK"> United Kingdom </option>
          <option value="GD"> Grenada </option>
          <option value="GE"> Georgia </option>
          <option value="GF"> French Guiana </option>
          <option value="GG"> Guernsey </option>
          <option value="GH"> Ghana </option>
          <option value="GI"> Gibraltar </option>
          <option value="GL"> Greenland </option>
          <option value="GM"> Gambia </option>
          <option value="GP"> Guadeloupe </option>
          <option value="GQ"> Equatorial Guinea </option>
          <option value="GR"> Greece </option>
          <option value="GT"> Guatemala </option>
          <option value="GU"> Guam </option>
          <option value="GW"> Guinea-bissau </option>
          <option value="GY"> Guyana </option>
          <option value="HK"> Hong Kong </option>
          <option value="HN"> Honduras </option>
          <option value="HR"> Croatia (local Name: Hrvatska) </option>
          <option value="HT"> Haiti </option>
          <option value="HU"> Hungary </option>
          <option value="ID"> Indonesia </option>
          <option value="IE"> Ireland </option>
          <option value="IL"> Israel </option>
          <option value="IM"> Isle Of Man </option>
          <option value="IN"> India </option>
          <option value="IO"> British Indian Ocean Territory </option>
          <option value="IQ"> Iraq </option>
          <option value="IR"> Iran (islamic Republic Of) </option>
          <option value="IS"> Iceland </option>
          <option value="IT"> Italy </option>
          <option value="JE"> Jersey </option>
          <option value="JM"> Jamaica </option>
          <option value="JO"> Jordan </option>
          <option value="JP"> Japan </option>
          <option value="KE"> Kenya </option>
          <option value="KG"> Kyrgyzstan </option>
          <option value="KH"> Cambodia </option>
          <option value="KI"> Kiribati </option>
          <option value="KN"> Saint Kitts And Nevis </option>
          <option value="KR"> Korea Republic Of </option>
          <option value="KW"> Kuwait </option>
          <option value="KY"> Cayman Islands </option>
          <option value="KZ"> Kazakhstan </option>
          <option value="LB"> Lebanon </option>
          <option value="LC"> Saint Lucia </option>
          <option value="LI"> Liechtenstein </option>
          <option value="LK"> Sri Lanka </option>
          <option value="LS"> Lesotho </option>
          <option value="LT"> Lithuania </option>
          <option value="LU"> Luxembourg </option>
          <option value="LV"> Latvia </option>
          <option value="LY"> Libyan Arab Jamahiriya </option>
          <option value="MA"> Morocco </option>
          <option value="MC"> Monaco </option>
          <option value="MD"> Moldova Republic Of </option>
          <option value="ME"> Montenegro </option>
          <option value="MG"> Madagascar </option>
          <option value="MH"> Marshall Islands </option>
          <option value="MK"> Macedonia The Former Yugoslav Republic O </option>
          <option value="ML"> Mali </option>
          <option value="MM"> Myanmar </option>
          <option value="MN"> Mongolia </option>
          <option value="MO"> Macau </option>
          <option value="MP"> Northern Mariana Islands </option>
          <option value="MR"> Mauritania </option>
          <option value="MS"> Montserrat </option>
          <option value="MT"> Malta </option>
          <option value="MU"> Mauritius </option>
          <option value="MV"> Maldives </option>
          <option value="MW"> Malawi </option>
          <option value="MX"> Mexico </option>
          <option value="MY"> Malaysia </option>
          <option value="MZ"> Mozambique </option>
          <option value="NA"> Namibia </option>
          <option value="NC"> New Caledonia </option>
          <option value="NE"> Niger </option>
          <option value="NF"> Norfolk Island </option>
          <option value="NG"> Nigeria </option>
          <option value="NI"> Nicaragua </option>
          <option value="NL"> Netherlands </option>
          <option value="NO"> Norway </option>
          <option value="NP"> Nepal </option>
          <option value="NR"> Nauru </option>
          <option value="NU"> Niue </option>
          <option value="NZ"> New Zealand </option>
          <option value="OM"> Oman </option>
          <option value="PA"> Panama </option>
          <option value="PE"> Peru </option>
          <option value="PF"> French Polynesia </option>
          <option value="PG"> Papua New Guinea </option>
          <option value="PH"> Philippines </option>
          <option value="PK"> Pakistan </option>
          <option value="PL"> Poland </option>
          <option value="PR"> Puerto Rico </option>
          <option value="PS"> Palestinian Territory Occupied </option>
          <option value="PT"> Portugal </option>
          <option value="PW"> Palau </option>
          <option value="PY"> Paraguay </option>
          <option value="QA"> Qatar </option>
          <option value="RE"> Reunion </option>
          <option value="RO"> Romania </option>
          <option value="RS"> Serbia </option>
          <option value="RU"> Russian Federation </option>
          <option value="RW"> Rwanda </option>
          <option value="SA"> Saudi Arabia </option>
          <option value="SB"> Solomon Islands </option>
          <option value="SC"> Seychelles </option>
          <option value="SD"> Sudan </option>
          <option value="SE"> Sweden </option>
          <option value="SG"> Singapore </option>
          <option value="SI"> Slovenia </option>
          <option value="SK"> Slovakia (slovak Republic) </option>
          <option value="SL"> Sierra Leone </option>
          <option value="SM"> San Marino </option>
          <option value="SN"> Senegal </option>
          <option value="SR"> Suriname </option>
          <option value="SV"> El Salvador </option>
          <option value="SY"> Syrian Arab Republic </option>
          <option value="SZ"> Swaziland </option>
          <option value="TC"> Turks And Caicos Islands </option>
          <option value="TG"> Togo </option>
          <option value="TH"> Thailand </option>
          <option value="TJ"> Tajikistan </option>
          <option value="TM"> Turkmenistan </option>
          <option value="TN"> Tunisia </option>
          <option value="TO"> Tonga </option>
          <option value="TR"> Turkey </option>
          <option value="TT"> Trinidad And Tobago </option>
          <option value="TV"> Tuvalu </option>
          <option value="TW"> Taiwan Province Of China </option>
          <option value="TZ"> Tanzania United Republic Of </option>
          <option value="UA"> Ukraine </option>
          <option value="UG"> Uganda </option>
          <option selected="&quot;selected&quot;" value="US"> United States </option>
          <option value="UY"> Uruguay </option>
          <option value="UZ"> Uzbekistan </option>
          <option value="VA"> Holy See (vatican City State) </option>
          <option value="VC"> Saint Vincent And The Grenadines </option>
          <option value="VE"> Venezuela </option>
          <option value="VG"> Virgin Islands (british) </option>
          <option value="VI"> Virgin Islands (u.s.) </option>
          <option value="VN"> Viet Nam </option>
          <option value="VU"> Vanuatu </option>
          <option value="WF"> Wallis And Futuna Islands </option>
          <option value="WS"> Samoa </option>
          <option value="YE"> Yemen </option>
          <option value="ZA"> South Africa </option>
          <option value="ZM"> Zambia </option>
          <option value="ZW"> Zimbabwe </option>
          <option value="ZZ"> Reserved </option>
          <option value="CI"> Cote D'ivoire </option>
          <option value="LA"> Lao People's Democratic Republic </option>
          <option value="4"> Bot 1 </option>
          <option value="5"> Hp New Orleans Office </option>
          <option value="PM"> St. Pierre And Miquelon </option>
          <option value="LR"> Liberia </option>
          <option value="MF">
          </option>
          <option value="GN"> Guinea </option>
          <option value="TL"> Timor-leste </option>
          <option value="KP"> Korea Democratic People's Republic Of </option>
          <option value="TD"> Chad </option>
          <option value="SO"> Somalia </option>
          <option value="TK"> Tokelau </option>
          <option value="DM"> Dominica </option>
          <option value="KM"> Comoros </option>
          <option value="ST"> Sao Tome And Principe </option>
          <option value="FK"> Falkland Islands (malvinas) </option>
          <option value="HM"> Heard Island And Mcdonald Islands </option>
          <option value="BV"> Bouvet Island </option>
          <option value="UM"> United States Minor Outlying Islands </option>
          <option value="MQ"> Martinique </option>
          <option value="AQ"> Antarctica </option>
          <option value="TF"> French Southern Territories </option>
          <option value="GS"> South Georgia And The South Sandwich Isl </option>
          <option value="YT"> Mayotte </option>
          <option value="1c"> Blake </option>
          <option value="1d"> Jen </option>
          <option value="1e"> Zach (c2c) </option>
          <option value="24"> Dan </option>
          <option value="25"> Kevin </option>
          <option value="27"> Ninfa_taylor </option>
          <option value="2a"> Delivery Team </option>
          <option value="2b"> Astrologic Answers </option>
          <option value="2c"> Test </option>
          <option value="2d"> Teamindia_1 </option>
          <option value="2e"> Teamindia_2 </option>
          <option value="2f"> Andrei </option>
          <option value="30"> Andrei1 </option>
          <option value="31"> Andrei2 </option>
          <option value="32"> Ronen(03242017) </option>
          <option value="33"> 160885 (jtl) </option>
          <option value="34"> Andrei Request </option>
          <option value="37"> Justyn </option>
        </select>
      </div>
      <div class="form-group">
        <label for="phone" class="form-required">Phone</label>
        <input type="tel" class="form-control form-control-sm " id="phone" name="phone" value="" required="">
      </div>
      <div class="form-group"><label for="fax" class="">Fax</label><input type="text" class="form-control form-control-sm" id="fax" name="fax"></div>
      <div class="row">
        <div class="col-12 col-sm-7">
          <div class="form-group"><label for="im" class="">IM</label><input type="text" class="form-control form-control-sm" id="im" name="im" value=""></div>
        </div>
        <div class="col-12 col-sm-5">
          <div class="form-group"><label for="improto" class="">IM Type</label><select class="form-control form-control-sm" id="improto" name="improto">
              <option value="MSN">MSN</option>
              <option value="AIM">AIM</option>
              <option value="Skype">Skype</option>
            </select></div>
        </div>
      </div>
      <div class="form-group">
        <label for="email" class="form-required">Email</label>
        <input type="email" class="form-control form-control-sm " id="email" name="email" value="" required="">
      </div>
      <div class="form-group">
        <label for="email2" class="form-required">Confirm Email</label>
        <input type="email" class="form-control form-control-sm " id="email2" name="email_confirmation" value="" required="">
      </div>
    </div>
    <div class="col-12 col-lg-6 px-lg-4">
      <div class="row">
        <div class="col">
          <h5>Additional Information</h5>
        </div>
      </div>
      <div class="form-group">
        <label for="offerurl" class="form-required">URL</label>
        <input type="text" class="form-control form-control-sm " id="offerurl" name="url" value="" required="">
      </div>
      <div class="form-group row mb-0 mt-3"><label class="form-check-label pl-3"><strong>Method of Acquisition</strong></label></div>
      <div class="form-check"><input class="form-check-input" type="checkbox" value="Cost per Lead" id="acquisitionmethod0" name="acquisitionmethod[]"><label class="form-check-label" for="acquisitionmethod0">Cost per Lead</label></div>
      <div class="form-check"><input class="form-check-input" type="checkbox" value="Cost per Click" id="acquisitionmethod1" name="acquisitionmethod[]"><label class="form-check-label" for="acquisitionmethod1">Cost per Click</label></div>
      <div class="form-check"><input class="form-check-input" type="checkbox" value="Cost per Sale" id="acquisitionmethod2" name="acquisitionmethod[]"><label class="form-check-label" for="acquisitionmethod2">Cost per Sale</label></div>
      <div class="form-group my-4"><label for="description" class="">Description</label><textarea class="form-control form-control-sm" id="description" rows="4" name="description"></textarea></div>
    </div>
  </div>
  <div class="row">
    <div class="col-12 mt-5 mb-2">
      <button type="submit" class="btn btn-block btn-primary">Submit</button>
    </div>
  </div>
</form>

POST https://partner.midenity.com/aff-application-submit

<form class="application-form" method="post" action="https://partner.midenity.com/aff-application-submit">
  <div class="row">
    <div class="application-form-left col-12 col-lg-6 px-lg-4">
      <div class="row">
        <div class="col">
          <h5>Contact Information</h5>
        </div>
      </div>
      <input type="hidden" name="_token" value="s3dkLE6ehFKBqkNeqqHTPpl6xbxaVDs6L8ksRGbB">
      <div class="form-group">
        <label for="firstname" class="form-required">First Name</label>
        <input type="text" class="form-control form-control-sm " id="firstname" name="fname" value="" required="">
      </div>
      <div class="form-group">
        <label for="lastname" class="form-required">Last Name</label>
        <input type="text" class="form-control form-control-sm " id="lastname" name="lname" value="" required="">
      </div>
      <div class="form-group">
        <label for="address1" class="form-required">Address</label>
        <input type="text" class="form-control form-control-sm " id="address1" name="address1" value="" maxlength="100" required="">
      </div>
      <div class="form-group">
        <label for="apt" class="">Apt/Suite</label>
        <input type="text" class="form-control form-control-sm " id="apt" name="address2" value="" maxlength="100">
      </div>
      <div class="form-group">
        <label for="city" class="form-required">City</label>
        <input type="text" class="form-control form-control-sm " id="city" name="city" value="" required="">
      </div>
      <div class="row">
        <div class="col-12 col-sm-7">
          <div class="form-group">
            <label for="state" class="form-required">State/Territory</label>
            <input type="text" class="form-control form-control-sm " id="affstate_text" value="" style="display:none">
            <select id="affstate_select" class="form-control form-control-sm " name="state" requires="">
              <option value="AL">Alabama</option>
              <option value="AK">Alaska</option>
              <option value="AZ">Arizona</option>
              <option value="AR">Arkansas</option>
              <option value="CA">California</option>
              <option value="CO">Colorado</option>
              <option value="CT">Connecticut</option>
              <option value="DE">Delaware</option>
              <option value="DC">District Of Columbia</option>
              <option value="FL">Florida</option>
              <option value="GA">Georgia</option>
              <option value="HI">Hawaii</option>
              <option value="ID">Idaho</option>
              <option value="IL">Illinois</option>
              <option value="IN">Indiana</option>
              <option value="IA">Iowa</option>
              <option value="KS">Kansas</option>
              <option value="KY">Kentucky</option>
              <option value="LA">Louisiana</option>
              <option value="ME">Maine</option>
              <option value="MD">Maryland</option>
              <option value="MA">Massachusetts</option>
              <option value="MI">Michigan</option>
              <option value="MN">Minnesota</option>
              <option value="MS">Mississippi</option>
              <option value="MO">Missouri</option>
              <option value="MT">Montana</option>
              <option value="NE">Nebraska</option>
              <option value="NV">Nevada</option>
              <option value="NH">New Hampshire</option>
              <option value="NJ">New Jersey</option>
              <option value="NM">New Mexico</option>
              <option value="NY">New York</option>
              <option value="NC">North Carolina</option>
              <option value="ND">North Dakota</option>
              <option value="OH">Ohio</option>
              <option value="OK">Oklahoma</option>
              <option value="OR">Oregon</option>
              <option value="PA">Pennsylvania</option>
              <option value="RI">Rhode Island</option>
              <option value="SC">South Carolina</option>
              <option value="SD">South Dakota</option>
              <option value="TN">Tennessee</option>
              <option value="TX">Texas</option>
              <option value="UT">Utah</option>
              <option value="VT">Vermont</option>
              <option value="VA">Virginia</option>
              <option value="WA">Washington</option>
              <option value="WV">West Virginia</option>
              <option value="WI">Wisconsin</option>
              <option value="WY">Wyoming</option>
            </select>
          </div>
        </div>
        <div class="col-12 col-sm-5">
          <div class="form-group">
            <label for="zip" class="form-required">Zip/Postal</label>
            <input type="text" class="form-control form-control-sm " id="zip" name="zip" value="" required="">
          </div>
        </div>
      </div>
      <div class="form-group">
        <label for="affcountry" class="form-required">Country</label>
        <select id="affcountry" class="form-control form-control-sm " name="country" required="">
          <option value="AD"> Andorra </option>
          <option value="AE"> United Arab Emirates </option>
          <option value="AF"> Afghanistan </option>
          <option value="AG"> Antigua And Barbuda </option>
          <option value="AI"> Anguilla </option>
          <option value="AL"> Albania </option>
          <option value="AM"> Armenia </option>
          <option value="AN"> Netherlands Antilles </option>
          <option value="AO"> Angola </option>
          <option value="AP"> Non-spec Asia Pas Location </option>
          <option value="AR"> Argentina </option>
          <option value="AS"> American Samoa </option>
          <option value="AT"> Austria </option>
          <option value="AU"> Australia </option>
          <option value="AW"> Aruba </option>
          <option value="AX"> &amp;#197;land Islands </option>
          <option value="AZ"> Azerbaijan </option>
          <option value="BA"> Bosnia And Herzegowina </option>
          <option value="BB"> Barbados </option>
          <option value="BD"> Bangladesh </option>
          <option value="BE"> Belgium </option>
          <option value="BF"> Burkina Faso </option>
          <option value="BG"> Bulgaria </option>
          <option value="BH"> Bahrain </option>
          <option value="BI"> Burundi </option>
          <option value="BJ"> Benin </option>
          <option value="BM"> Bermuda </option>
          <option value="BN"> Brunei Darussalam </option>
          <option value="BO"> Bolivia </option>
          <option value="BR"> Brazil </option>
          <option value="BS"> Bahamas </option>
          <option value="BT"> Bhutan </option>
          <option value="BW"> Botswana </option>
          <option value="BY"> Belarus </option>
          <option value="BZ"> Belize </option>
          <option value="CA"> Canada </option>
          <option value="CD"> Congo The Democratic Republic Of The </option>
          <option value="CF"> Central African Republic </option>
          <option value="CG"> Congo </option>
          <option value="CH"> Switzerland </option>
          <option value="CK"> Cook Islands </option>
          <option value="CL"> Chile </option>
          <option value="CM"> Cameroon </option>
          <option value="CN"> China </option>
          <option value="CO"> Colombia </option>
          <option value="CR"> Costa Rica </option>
          <option value="CS"> Serbia And Montenegro </option>
          <option value="CU"> Cuba </option>
          <option value="CV"> Cape Verde </option>
          <option value="CY"> Cyprus </option>
          <option value="CZ"> Czech Republic </option>
          <option value="DE"> Germany </option>
          <option value="DJ"> Djibouti </option>
          <option value="DK"> Denmark </option>
          <option value="DO"> Dominican Republic </option>
          <option value="DZ"> Algeria </option>
          <option value="EC"> Ecuador </option>
          <option value="EE"> Estonia </option>
          <option value="EG"> Egypt </option>
          <option value="ER"> Eritrea </option>
          <option value="ES"> Spain </option>
          <option value="ET"> Ethiopia </option>
          <option value="EU"> European Union </option>
          <option value="FI"> Finland </option>
          <option value="FJ"> Fiji </option>
          <option value="FM"> Micronesia Federated States Of </option>
          <option value="FO"> Faroe Islands </option>
          <option value="FR"> France </option>
          <option value="GA"> Gabon </option>
          <option value="UK"> United Kingdom </option>
          <option value="GD"> Grenada </option>
          <option value="GE"> Georgia </option>
          <option value="GF"> French Guiana </option>
          <option value="GG"> Guernsey </option>
          <option value="GH"> Ghana </option>
          <option value="GI"> Gibraltar </option>
          <option value="GL"> Greenland </option>
          <option value="GM"> Gambia </option>
          <option value="GP"> Guadeloupe </option>
          <option value="GQ"> Equatorial Guinea </option>
          <option value="GR"> Greece </option>
          <option value="GT"> Guatemala </option>
          <option value="GU"> Guam </option>
          <option value="GW"> Guinea-bissau </option>
          <option value="GY"> Guyana </option>
          <option value="HK"> Hong Kong </option>
          <option value="HN"> Honduras </option>
          <option value="HR"> Croatia (local Name: Hrvatska) </option>
          <option value="HT"> Haiti </option>
          <option value="HU"> Hungary </option>
          <option value="ID"> Indonesia </option>
          <option value="IE"> Ireland </option>
          <option value="IL"> Israel </option>
          <option value="IM"> Isle Of Man </option>
          <option value="IN"> India </option>
          <option value="IO"> British Indian Ocean Territory </option>
          <option value="IQ"> Iraq </option>
          <option value="IR"> Iran (islamic Republic Of) </option>
          <option value="IS"> Iceland </option>
          <option value="IT"> Italy </option>
          <option value="JE"> Jersey </option>
          <option value="JM"> Jamaica </option>
          <option value="JO"> Jordan </option>
          <option value="JP"> Japan </option>
          <option value="KE"> Kenya </option>
          <option value="KG"> Kyrgyzstan </option>
          <option value="KH"> Cambodia </option>
          <option value="KI"> Kiribati </option>
          <option value="KN"> Saint Kitts And Nevis </option>
          <option value="KR"> Korea Republic Of </option>
          <option value="KW"> Kuwait </option>
          <option value="KY"> Cayman Islands </option>
          <option value="KZ"> Kazakhstan </option>
          <option value="LB"> Lebanon </option>
          <option value="LC"> Saint Lucia </option>
          <option value="LI"> Liechtenstein </option>
          <option value="LK"> Sri Lanka </option>
          <option value="LS"> Lesotho </option>
          <option value="LT"> Lithuania </option>
          <option value="LU"> Luxembourg </option>
          <option value="LV"> Latvia </option>
          <option value="LY"> Libyan Arab Jamahiriya </option>
          <option value="MA"> Morocco </option>
          <option value="MC"> Monaco </option>
          <option value="MD"> Moldova Republic Of </option>
          <option value="ME"> Montenegro </option>
          <option value="MG"> Madagascar </option>
          <option value="MH"> Marshall Islands </option>
          <option value="MK"> Macedonia The Former Yugoslav Republic O </option>
          <option value="ML"> Mali </option>
          <option value="MM"> Myanmar </option>
          <option value="MN"> Mongolia </option>
          <option value="MO"> Macau </option>
          <option value="MP"> Northern Mariana Islands </option>
          <option value="MR"> Mauritania </option>
          <option value="MS"> Montserrat </option>
          <option value="MT"> Malta </option>
          <option value="MU"> Mauritius </option>
          <option value="MV"> Maldives </option>
          <option value="MW"> Malawi </option>
          <option value="MX"> Mexico </option>
          <option value="MY"> Malaysia </option>
          <option value="MZ"> Mozambique </option>
          <option value="NA"> Namibia </option>
          <option value="NC"> New Caledonia </option>
          <option value="NE"> Niger </option>
          <option value="NF"> Norfolk Island </option>
          <option value="NG"> Nigeria </option>
          <option value="NI"> Nicaragua </option>
          <option value="NL"> Netherlands </option>
          <option value="NO"> Norway </option>
          <option value="NP"> Nepal </option>
          <option value="NR"> Nauru </option>
          <option value="NU"> Niue </option>
          <option value="NZ"> New Zealand </option>
          <option value="OM"> Oman </option>
          <option value="PA"> Panama </option>
          <option value="PE"> Peru </option>
          <option value="PF"> French Polynesia </option>
          <option value="PG"> Papua New Guinea </option>
          <option value="PH"> Philippines </option>
          <option value="PK"> Pakistan </option>
          <option value="PL"> Poland </option>
          <option value="PR"> Puerto Rico </option>
          <option value="PS"> Palestinian Territory Occupied </option>
          <option value="PT"> Portugal </option>
          <option value="PW"> Palau </option>
          <option value="PY"> Paraguay </option>
          <option value="QA"> Qatar </option>
          <option value="RE"> Reunion </option>
          <option value="RO"> Romania </option>
          <option value="RS"> Serbia </option>
          <option value="RU"> Russian Federation </option>
          <option value="RW"> Rwanda </option>
          <option value="SA"> Saudi Arabia </option>
          <option value="SB"> Solomon Islands </option>
          <option value="SC"> Seychelles </option>
          <option value="SD"> Sudan </option>
          <option value="SE"> Sweden </option>
          <option value="SG"> Singapore </option>
          <option value="SI"> Slovenia </option>
          <option value="SK"> Slovakia (slovak Republic) </option>
          <option value="SL"> Sierra Leone </option>
          <option value="SM"> San Marino </option>
          <option value="SN"> Senegal </option>
          <option value="SR"> Suriname </option>
          <option value="SV"> El Salvador </option>
          <option value="SY"> Syrian Arab Republic </option>
          <option value="SZ"> Swaziland </option>
          <option value="TC"> Turks And Caicos Islands </option>
          <option value="TG"> Togo </option>
          <option value="TH"> Thailand </option>
          <option value="TJ"> Tajikistan </option>
          <option value="TM"> Turkmenistan </option>
          <option value="TN"> Tunisia </option>
          <option value="TO"> Tonga </option>
          <option value="TR"> Turkey </option>
          <option value="TT"> Trinidad And Tobago </option>
          <option value="TV"> Tuvalu </option>
          <option value="TW"> Taiwan Province Of China </option>
          <option value="TZ"> Tanzania United Republic Of </option>
          <option value="UA"> Ukraine </option>
          <option value="UG"> Uganda </option>
          <option selected="&quot;selected&quot;" value="US"> United States </option>
          <option value="UY"> Uruguay </option>
          <option value="UZ"> Uzbekistan </option>
          <option value="VA"> Holy See (vatican City State) </option>
          <option value="VC"> Saint Vincent And The Grenadines </option>
          <option value="VE"> Venezuela </option>
          <option value="VG"> Virgin Islands (british) </option>
          <option value="VI"> Virgin Islands (u.s.) </option>
          <option value="VN"> Viet Nam </option>
          <option value="VU"> Vanuatu </option>
          <option value="WF"> Wallis And Futuna Islands </option>
          <option value="WS"> Samoa </option>
          <option value="YE"> Yemen </option>
          <option value="ZA"> South Africa </option>
          <option value="ZM"> Zambia </option>
          <option value="ZW"> Zimbabwe </option>
          <option value="ZZ"> Reserved </option>
          <option value="CI"> Cote D'ivoire </option>
          <option value="LA"> Lao People's Democratic Republic </option>
          <option value="4"> Bot 1 </option>
          <option value="5"> Hp New Orleans Office </option>
          <option value="PM"> St. Pierre And Miquelon </option>
          <option value="LR"> Liberia </option>
          <option value="MF">
          </option>
          <option value="GN"> Guinea </option>
          <option value="TL"> Timor-leste </option>
          <option value="KP"> Korea Democratic People's Republic Of </option>
          <option value="TD"> Chad </option>
          <option value="SO"> Somalia </option>
          <option value="TK"> Tokelau </option>
          <option value="DM"> Dominica </option>
          <option value="KM"> Comoros </option>
          <option value="ST"> Sao Tome And Principe </option>
          <option value="FK"> Falkland Islands (malvinas) </option>
          <option value="HM"> Heard Island And Mcdonald Islands </option>
          <option value="BV"> Bouvet Island </option>
          <option value="UM"> United States Minor Outlying Islands </option>
          <option value="MQ"> Martinique </option>
          <option value="AQ"> Antarctica </option>
          <option value="TF"> French Southern Territories </option>
          <option value="GS"> South Georgia And The South Sandwich Isl </option>
          <option value="YT"> Mayotte </option>
          <option value="1c"> Blake </option>
          <option value="1d"> Jen </option>
          <option value="1e"> Zach (c2c) </option>
          <option value="24"> Dan </option>
          <option value="25"> Kevin </option>
          <option value="27"> Ninfa_taylor </option>
          <option value="2a"> Delivery Team </option>
          <option value="2b"> Astrologic Answers </option>
          <option value="2c"> Test </option>
          <option value="2d"> Teamindia_1 </option>
          <option value="2e"> Teamindia_2 </option>
          <option value="2f"> Andrei </option>
          <option value="30"> Andrei1 </option>
          <option value="31"> Andrei2 </option>
          <option value="32"> Ronen(03242017) </option>
          <option value="33"> 160885 (jtl) </option>
          <option value="34"> Andrei Request </option>
          <option value="37"> Justyn </option>
        </select>
      </div>
      <div class="form-group">
        <label for="phone" class="form-required">Phone</label>
        <input type="tel" class="form-control form-control-sm " id="phone" name="phone" value="" required="">
      </div>
      <div class="row mt-5">
        <div class="col">
          <h5>Login Information</h5>
        </div>
      </div>
      <div class="form-group">
        <label for="email" class="form-required">Email</label>
        <input type="email" class="form-control form-control-sm " id="email" name="email" value="" required="">
      </div>
      <div class="form-group">
        <label for="email2" class="form-required">Confirm Email</label>
        <input type="email" class="form-control form-control-sm " id="email2" name="email_confirmation" value="" required="">
      </div>
      <div class="form-group">
        <label for="username" class="form-required">Username</label>
        <input type="text" class="form-control form-control-sm " id="username" name="username" value="" required="" minlength="6" maxlength="15">
      </div>
      <div class="form-group">
        <label for="password" class="form-required">Password</label>
        <input type="password" class="form-control form-control-sm " id="password" name="password" value="" required="" minlength="6" maxlength="15">
      </div>
      <div class="form-group">
        <label for="password2" class="form-required">Confirm Password</label>
        <input type="password" class="form-control form-control-sm " id="password2" name="password_confirmation" value="" required="" minlength="6" maxlength="15">
      </div>
    </div>
    <div class="col-12 col-lg-6 px-lg-4">
      <div class="row">
        <div class="col">
          <h5>Payment Information</h5>
        </div>
      </div>
      <div class="form-group">
        <label style="visibility:hidden;"></label>
        <div class="custom-control custom-checkbox mt-3">
          <input type="checkbox" id="checkbox-same-as" class="custom-control-input">
          <label for="checkbox-same-as" class="custom-control-label">Same as Contact Information</label>
        </div>
      </div>
      <div class="form-group">
        <label for="company" class="form-required">Company</label>
        <input type="text" class="form-control form-control-sm " id="company" name="company" value="" required="">
      </div>
      <div class="form-group">
        <label for="paytoaddress1" class="form-required">Address</label>
        <input type="text" class="form-control form-control-sm " id="paytoaddress1" name="paytoaddress1" value="" maxlength="100" required="">
      </div>
      <div class="form-group">
        <label for="paytoaddress2" class="">Apt/Suite</label>
        <input type="text" class="form-control form-control-sm " id="paytoaddress2" name="paytoaddress2" value="" maxlength="100">
      </div>
      <div class="form-group">
        <label for="paytocity" class="form-required">City</label>
        <input type="text" class="form-control form-control-sm " id="paytocity" name="paytocity" value="" required="">
      </div>
      <div class="row">
        <div class="col-12 col-sm-7">
          <div class="form-group">
            <label for="paytostate" class="form-required">State/Territory</label>
            <input type="text" class="form-control form-control-sm " id="affpaytostate_text" value="" style="display:none">
            <select id="affpaytostate_select" class="form-control form-control-sm " name="paytostate" requires="">
              <option value="AL">Alabama</option>
              <option value="AK">Alaska</option>
              <option value="AZ">Arizona</option>
              <option value="AR">Arkansas</option>
              <option value="CA">California</option>
              <option value="CO">Colorado</option>
              <option value="CT">Connecticut</option>
              <option value="DE">Delaware</option>
              <option value="DC">District Of Columbia</option>
              <option value="FL">Florida</option>
              <option value="GA">Georgia</option>
              <option value="HI">Hawaii</option>
              <option value="ID">Idaho</option>
              <option value="IL">Illinois</option>
              <option value="IN">Indiana</option>
              <option value="IA">Iowa</option>
              <option value="KS">Kansas</option>
              <option value="KY">Kentucky</option>
              <option value="LA">Louisiana</option>
              <option value="ME">Maine</option>
              <option value="MD">Maryland</option>
              <option value="MA">Massachusetts</option>
              <option value="MI">Michigan</option>
              <option value="MN">Minnesota</option>
              <option value="MS">Mississippi</option>
              <option value="MO">Missouri</option>
              <option value="MT">Montana</option>
              <option value="NE">Nebraska</option>
              <option value="NV">Nevada</option>
              <option value="NH">New Hampshire</option>
              <option value="NJ">New Jersey</option>
              <option value="NM">New Mexico</option>
              <option value="NY">New York</option>
              <option value="NC">North Carolina</option>
              <option value="ND">North Dakota</option>
              <option value="OH">Ohio</option>
              <option value="OK">Oklahoma</option>
              <option value="OR">Oregon</option>
              <option value="PA">Pennsylvania</option>
              <option value="RI">Rhode Island</option>
              <option value="SC">South Carolina</option>
              <option value="SD">South Dakota</option>
              <option value="TN">Tennessee</option>
              <option value="TX">Texas</option>
              <option value="UT">Utah</option>
              <option value="VT">Vermont</option>
              <option value="VA">Virginia</option>
              <option value="WA">Washington</option>
              <option value="WV">West Virginia</option>
              <option value="WI">Wisconsin</option>
              <option value="WY">Wyoming</option>
            </select>
          </div>
        </div>
        <div class="col-12 col-sm-5">
          <div class="form-group">
            <label for="paytozip" class="form-required">Zip/Postal</label>
            <input type="text" class="form-control form-control-sm " id="paytozip" name="paytozip" value="" required="">
          </div>
        </div>
      </div>
      <div class="form-group">
        <label for="affpaytocountry" class="form-required">Country</label>
        <select id="affpaytocountry" class="form-control form-control-sm " name="paytocountry" required="">
          <option value="AD"> Andorra </option>
          <option value="AE"> United Arab Emirates </option>
          <option value="AF"> Afghanistan </option>
          <option value="AG"> Antigua And Barbuda </option>
          <option value="AI"> Anguilla </option>
          <option value="AL"> Albania </option>
          <option value="AM"> Armenia </option>
          <option value="AN"> Netherlands Antilles </option>
          <option value="AO"> Angola </option>
          <option value="AP"> Non-spec Asia Pas Location </option>
          <option value="AR"> Argentina </option>
          <option value="AS"> American Samoa </option>
          <option value="AT"> Austria </option>
          <option value="AU"> Australia </option>
          <option value="AW"> Aruba </option>
          <option value="AX"> &amp;#197;land Islands </option>
          <option value="AZ"> Azerbaijan </option>
          <option value="BA"> Bosnia And Herzegowina </option>
          <option value="BB"> Barbados </option>
          <option value="BD"> Bangladesh </option>
          <option value="BE"> Belgium </option>
          <option value="BF"> Burkina Faso </option>
          <option value="BG"> Bulgaria </option>
          <option value="BH"> Bahrain </option>
          <option value="BI"> Burundi </option>
          <option value="BJ"> Benin </option>
          <option value="BM"> Bermuda </option>
          <option value="BN"> Brunei Darussalam </option>
          <option value="BO"> Bolivia </option>
          <option value="BR"> Brazil </option>
          <option value="BS"> Bahamas </option>
          <option value="BT"> Bhutan </option>
          <option value="BW"> Botswana </option>
          <option value="BY"> Belarus </option>
          <option value="BZ"> Belize </option>
          <option value="CA"> Canada </option>
          <option value="CD"> Congo The Democratic Republic Of The </option>
          <option value="CF"> Central African Republic </option>
          <option value="CG"> Congo </option>
          <option value="CH"> Switzerland </option>
          <option value="CK"> Cook Islands </option>
          <option value="CL"> Chile </option>
          <option value="CM"> Cameroon </option>
          <option value="CN"> China </option>
          <option value="CO"> Colombia </option>
          <option value="CR"> Costa Rica </option>
          <option value="CS"> Serbia And Montenegro </option>
          <option value="CU"> Cuba </option>
          <option value="CV"> Cape Verde </option>
          <option value="CY"> Cyprus </option>
          <option value="CZ"> Czech Republic </option>
          <option value="DE"> Germany </option>
          <option value="DJ"> Djibouti </option>
          <option value="DK"> Denmark </option>
          <option value="DO"> Dominican Republic </option>
          <option value="DZ"> Algeria </option>
          <option value="EC"> Ecuador </option>
          <option value="EE"> Estonia </option>
          <option value="EG"> Egypt </option>
          <option value="ER"> Eritrea </option>
          <option value="ES"> Spain </option>
          <option value="ET"> Ethiopia </option>
          <option value="EU"> European Union </option>
          <option value="FI"> Finland </option>
          <option value="FJ"> Fiji </option>
          <option value="FM"> Micronesia Federated States Of </option>
          <option value="FO"> Faroe Islands </option>
          <option value="FR"> France </option>
          <option value="GA"> Gabon </option>
          <option value="UK"> United Kingdom </option>
          <option value="GD"> Grenada </option>
          <option value="GE"> Georgia </option>
          <option value="GF"> French Guiana </option>
          <option value="GG"> Guernsey </option>
          <option value="GH"> Ghana </option>
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          <option value="PF"> French Polynesia </option>
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          <option value="PL"> Poland </option>
          <option value="PR"> Puerto Rico </option>
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          <option value="PW"> Palau </option>
          <option value="PY"> Paraguay </option>
          <option value="QA"> Qatar </option>
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          <option value="RO"> Romania </option>
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          <option value="RW"> Rwanda </option>
          <option value="SA"> Saudi Arabia </option>
          <option value="SB"> Solomon Islands </option>
          <option value="SC"> Seychelles </option>
          <option value="SD"> Sudan </option>
          <option value="SE"> Sweden </option>
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          <option value="SI"> Slovenia </option>
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          <option value="TZ"> Tanzania United Republic Of </option>
          <option value="UA"> Ukraine </option>
          <option value="UG"> Uganda </option>
          <option selected="&quot;selected&quot;" value="US"> United States </option>
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          <option value="FK"> Falkland Islands (malvinas) </option>
          <option value="HM"> Heard Island And Mcdonald Islands </option>
          <option value="BV"> Bouvet Island </option>
          <option value="UM"> United States Minor Outlying Islands </option>
          <option value="MQ"> Martinique </option>
          <option value="AQ"> Antarctica </option>
          <option value="TF"> French Southern Territories </option>
          <option value="GS"> South Georgia And The South Sandwich Isl </option>
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          <option value="30"> Andrei1 </option>
          <option value="31"> Andrei2 </option>
          <option value="32"> Ronen(03242017) </option>
          <option value="33"> 160885 (jtl) </option>
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