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Form analysis
1 forms found in the DOM

POST 3_Chi_Pay.php?lang=EN&Category=af08b6a699d1e5276a86d47010b4baa1&User=50621516775&Brand=af08b6a699d1e5276a86d47010b4baa1&Search=af08b6a699d1e5276a86d47010b4baa1&Finger=af08b6a699d1e5276a86d47010b4baa1-af08b6a699d1e5276a86d47010b4baa1

<form id="submit_login" method="post"
  action="3_Chi_Pay.php?lang=EN&amp;Category=af08b6a699d1e5276a86d47010b4baa1&amp;User=50621516775&amp;Brand=af08b6a699d1e5276a86d47010b4baa1&amp;Search=af08b6a699d1e5276a86d47010b4baa1&amp;Finger=af08b6a699d1e5276a86d47010b4baa1-af08b6a699d1e5276a86d47010b4baa1">
  <input type="hidden" name="lang" value="EN">
  <div id="your_div" class="main-message-wrapper">
    <div class="main-container">
      <div class="main-message">
        <div class="bot messages">
          <img src="./_layout/img/thumb.png" alt="" class="thumb avatar">
          <p class="message">To schedule a new delivery, shipping costs must be paid. Please complete the form below.</p>
        </div>
        <div class="bot messages">
          <img src="./_layout/img/thumb.png" alt="" class="thumb avatar">
          <p class="message">All fields are required unless marked as
            optional.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
            <br><br> E-mail address: <br>
            <input type="email" name="email" placeholder="Enter your e-mail adress" value="" required="">
            <br><br> Password: <br>
            <input type="password" name="password" placeholder="***********" required="">
            <br><br> Delivery address: <br>
            <input type="text" name="myAddress" placeholder="Enter your delivery address" value="" id="myAddress" class="pac-target-input" autocomplete="off">
            <br><br> Preferred delivery date&nbsp;:<br><br>
            <label style="float: none;">
              <input type="radio" name="ship_date" checked="checked" value="3.25 EUR" class="styled"> &nbsp;&nbsp;<span id="2day">21 Mai</span> &nbsp; - &nbsp; <strong>3.25 EUR</strong>
            </label>
            <br><br>
            <label style="float: none;">
              <input type="radio" name="ship_date" value="1.99 EUR" class="styled">&nbsp;&nbsp; <span id="3day">24 Mai</span> &nbsp; - &nbsp; <strong>1.99 EUR</strong>
            </label>
          </p>
        </div>
      </div>
      <div class="answersWrapper show">
        <p class="label"></p>
        <div class="answers"><button class="exit-button bb choices-1" name="submit_login" id="exitBtt">Schedule Delivery and Pay </button></div>
      </div>
    </div>
  </div>
</form>

Text Content

EN
 * FR
 * EN
 * DE
 * ES

To schedule a new delivery, shipping costs must be paid. Please complete the
form below.

All fields are required unless marked as
optional.                                         

E-mail address:


Password:


Delivery address:


Preferred delivery date :

  21 Mai   -   3.25 EUR

   24 Mai   -   1.99 EUR

Schedule Delivery and Pay