ican.id Open in urlscan Pro
103.176.78.63  Public Scan

URL: https://ican.id/registrasi/user
Submission: On December 19 via manual from ID — Scanned from CH

Form analysis 1 forms found in the DOM

POST https://ican.id/registerSave

<form method="POST" action="https://ican.id/registerSave">
  <input type="hidden" name="_token" value="qC5Tf7VFUGn7Q63pdOv8Fx8QmsJ3aVtkvvmS4y7w">
  <div class="row mb-3">
    <label for="name" class="col-md-4 col-form-label text-md-end">Name</label>
    <div class="col-md-6">
      <input id="name" type="text" class="form-control " name="name" value="" required="" autocomplete="name" autofocus="" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <label for="fullname" class="col-md-4 col-form-label text-md-end">Full Name</label>
    <div class="col-md-6">
      <input id="fullname" type="text" class="form-control " name="fullname" value="" required="" autocomplete="fullname" autofocus="" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <label for="telp" class="col-md-4 col-form-label text-md-end">Telephone</label>
    <div class="col-md-6">
      <input id="telp" type="text" class="form-control " name="telp" value="" required="" autocomplete="telp" autofocus="" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <label for="email" class="col-md-4 col-form-label text-md-end">Email Address</label>
    <div class="col-md-6">
      <input id="email" type="email" class="form-control " name="email" value="" required="" autocomplete="email" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <label for="kecamatan" class="col-md-4 col-form-label text-md-end">Kecamatan</label>
    <div class="col-md-6">
      <div class="input-group">
        <select class="form-control kecamatan select2-hidden-accessible" id="kecamatan" name="kecamatan" required="" data-select2-id="select2-data-kecamatan" tabindex="-1" aria-hidden="true"></select><span
          class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="select2-data-1-a79a" style="width: 385px;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox"
              aria-haspopup="true" aria-expanded="false" tabindex="0" aria-disabled="false" aria-labelledby="select2-kecamatan-container"><span class="select2-selection__rendered" id="select2-kecamatan-container" role="textbox"
                aria-readonly="true"><span class="select2-selection__placeholder">Input Kecamatan</span></span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper"
            aria-hidden="true"></span></span>
      </div>
    </div>
  </div>
  <div class="row mb-3">
    <label for="kelurahan" class="col-md-4 col-form-label text-md-end">Kelurahan</label>
    <div class="col-md-6">
      <input id="kelurahan" type="text" class="form-control " name="kelurahan" value="" required="" autocomplete="kelurahan" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <label for="password" class="col-md-4 col-form-label text-md-end">Alamat</label>
    <div class="col-md-6">
      <textarea class="form-control" id="FormControlTextarea1" rows="3" name="address" required=""></textarea>
    </div>
  </div>
  <div class="row mb-3">
    <label for="password" class="col-md-4 col-form-label text-md-end">Password</label>
    <div class="col-md-6">
      <input id="password" type="password" class="form-control " name="password" required="" autocomplete="new-password" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <label for="password-confirm" class="col-md-4 col-form-label text-md-end">Confirm Password</label>
    <div class="col-md-6">
      <input id="password-confirm" type="password" class="form-control" name="password_confirmation" required="" autocomplete="new-password" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <label for="password-confirm" class="col-md-4 col-form-label text-md-end">Refferal</label>
    <div class="col-md-6">
      <input id="refferal" type="text" class="form-control" name="refferal" value="" onfocus="focused(this)" onfocusout="defocused(this)">
    </div>
  </div>
  <div class="row mb-3">
    <div class="col d-flex justify-content-center">
      <button type="submit" class="btn btn-primary"> Register </button>
    </div>
  </div>
</form>

Text Content

REGISTER


Name

Full Name

Telephone

Email Address

Kecamatan
Input Kecamatan
Kelurahan

Alamat

Password

Confirm Password

Refferal

Register

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