ehr.i-admin.com Open in urlscan Pro
42.99.135.148  Public Scan

Form analysis
1 forms found in the DOM

Name: form1 — POST catalog

<form name="form1" method="post" action="catalog" onsubmit="return form_check(document.form1)" autocomplete="OFF">
  <input type="hidden" name="event" value="NEWUSER_CHECK">
  <input type="hidden" name="module" value="RegisterUser">
  <input type="hidden" name="cmd" value="verifyForm1">
  <input type="hidden" name="dob" value="">
  <input type="hidden" name="questionFlag" value="">
  <input type="hidden" name="employeeIdHolder" value="">
  <input type="hidden" name="surnameHolder" value="">
  <input type="hidden" name="givenameHolder" value="">
  <input type="hidden" name="emailHolder" value="">
  <input type="hidden" name="eventidHolder" value="">
  <input type="hidden" name="dobYearHolder" value="">
  <table width="550" border="0" cellspacing="0" cellpadding="5">
    <tbody>
      <tr>
        <td width="230" height="25">Invite Key</td>
        <td width="214" height="25">
          <input type="text" id="eventid" value="720BA1FCD254FA28980344356F9F8D6819695B0C" readonly="readonly" size="50" tabindex="1">
        </td>
      </tr>
      <tr>
        <td width="230" height="25">Employee ID</td>
        <td width="214" height="25">
          <input type="text" id="employeeid" maxlength="20" onchange="clearPrevMsg()" value="" size="30" tabindex="1">
        </td>
        <td rowspan="4" width="46" height="25">
          <div align="center"><input type="image" border="0" name="submit" src="images/button2.gif" width="41" height="41" tabindex="8"></div>
        </td>
      </tr>
      <tr>
        <td width="230" height="25">Sur Name</td>
        <td width="214" height="25">
          <input type="text" id="surname" name="surname" value="" size="30" maxlength="20" tabindex="1">
        </td>
      </tr>
      <tr>
        <td width="230" height="25">Given Name</td>
        <td width="214" height="25">
          <input type="text" id="givename" name="givename" value="" size="30" maxlength="20" tabindex="1">
        </td>
      </tr>
      <tr>
        <td width="230">Email ID</td>
        <td width="150">
          <input type="text" id="email" name="email" size="30" readonly="readonly" value="etong@cppib.com" maxlength="100" tabindex="6">
        </td>
      </tr>
      <tr>
        <td width="230" height="28">Date of birth</td>
        <td width="214" height="28">
          <select name="dob_day" onchange="clearPrevMsg()" tabindex="2">
            <option value="01">1</option>
            <option value="02">2</option>
            <option value="03">3</option>
            <option value="04">4</option>
            <option value="05">5</option>
            <option value="06">6</option>
            <option value="07">7</option>
            <option value="08">8</option>
            <option value="09">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>
          <select name="dob_month" onchange="clearPrevMsg()" tabindex="3">
            <option value="01">January</option>
            <option value="02">February</option>
            <option value="03">March</option>
            <option value="04">April</option>
            <option value="05">May</option>
            <option value="06">June</option>
            <option value="07">July</option>
            <option value="08">August</option>
            <option value="09">September</option>
            <option value="10">October</option>
            <option value="11">November</option>
            <option value="12">December</option>
          </select>
          <select name="dob_year" onchange="clearPrevMsg()" tabindex="3" style="width: 73px;">
            <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>
        </td>
      </tr>
      <tr>
        <td></td>
        <td id="questionMessage">
          <font color="red">Enter the captcha as shown in the image. Note: Letters are case sensitive</font>
        </td>
      </tr>
      <tr>
        <td></td>
        <td id="captcha"><img src="catalog?module=Captcha" border="0" id="captchaImg" align="middle">&nbsp;<img onclick="reloadCaptcha()" name="submitRefresh" src="images/login/refresh.png">&nbsp;<img id="next" onclick="questionMark()"
            src="images/login/questionMark.png" border="0" height="23"></td>
      </tr>
      <tr>
        <td width="210" height="28"></td>
        <td>
          <input class="post" id="captchaBox" style="WIDTH: 220px; font-weight: bold;" onchange="clearmsg()" maxlength="25" size="25" name="captchaResponse">
        </td>
      </tr>
      <tr>
        <td>
        </td>
        <td id="formMismatchwarning" style="display: none;">
          <font color="red">You have entered the wrong Employee ID or Date of Birth. Please try again.</font>
        </td>
      </tr>
      <tr>
        <td>
        </td>
        <td id="wrongcaptcha" style="display: none;">
          <font color="red">You have entered the wrong Image Text. Please try again.</font>
        </td>
      </tr>
      <tr>
        <td></td>
        <td id="warnMsg3" style="display: none;">
          <font color="red">This field is required.</font>
        </td>
      </tr>
      <tr>
        <td></td>
        <td colspan="2"><input id="accept" type="checkbox"> &nbsp; <a href="javascript:openPrivacyStatement('registration_agreement.html');">I agree to the terms and conditions...</a></td>
      </tr>
    </tbody>
  </table>
</form>

Text Content

User Maintenance Details

 

STEP 01 - User details

Please fill in the following information to proceed to the next step.

 

Invite Key Employee ID

Sur Name Given Name Email ID Date of birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May
June July August September October November December 2024 2023 2022 2021 2020
2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004
2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988
1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972
1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956
1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940
1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908
1907 1906 1905 1904 1903 1902 1901 1900 Enter the captcha as shown in the image.
Note: Letters are case sensitive    You have entered the wrong Employee ID or
Date of Birth. Please try again. You have entered the wrong Image Text. Please
try again. This field is required.   I agree to the terms and conditions...

 

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