www.test.erolperkasamandiri.co.id
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103.152.242.5
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URL:
http://www.test.erolperkasamandiri.co.id/
Submission: On December 06 via api from US — Scanned from US
Submission: On December 06 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
POST http://www.test.erolperkasamandiri.co.id/participant
<form action="http://www.test.erolperkasamandiri.co.id/participant" method="POST" enctype="multipart/form-data" class="" novalidate="">
<input type="hidden" name="_token" value="GnuGgSejiYk4UJV2NnVMZ7ix8KdhDJG81VFEQsCT">
<section class="bs-validation">
<div class="row">
<!-- Bootstrap Validation -->
<div class="col-12">
<div class="card">
<div class="card-header">
<h4 class="card-title">EROL PERKASA MANDIRI</h4>
</div>
<div class="card-body">
<input type="hidden" id="price" name="price" value="">
<input type="hidden" id="tmpcodereg" name="tmpcodereg" value="0">
<div class="row">
<div class="col-md-6">
<div class="mb-1">
<label class="form-label" for="select-country1">EVENT <span style="color:red;">*</span></label>
<div class="position-relative">
<div class="position-relative"><select class="form-select select2 select2-hidden-accessible" name="id_event" id="id_event" required="" tabindex="-1" aria-hidden="true" data-select2-id="id_event">
<option value="" data-select2-id="83">Select Event</option>
<option value="1">Event Erol</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="82" style="width: 685px;"><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-id_event-container"><span class="select2-selection__rendered" id="select2-id_event-container" role="textbox"
aria-readonly="true"><span class="select2-selection__placeholder">Select value</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 class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please select your package</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Full Name <span style="color:red;">*</span></label>
<input type="text" id="fullname" name="fullname" class="form-control" placeholder="input full name" aria-label="fullname" aria-describedby="basic-addon-name" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your fullname.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Nick Name <span style="color:red;">*</span></label>
<input type="text" id="nickname" name="nickname" class="form-control" placeholder="input nickname" aria-label="nickname" aria-describedby="basic-addon-name" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your nickname.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Place of Birth <span style="color:red;">*</span></label>
<input type="text" id="place_of_birth" name="place_of_birth" class="form-control" placeholder="input place of birth" aria-label="place_of_birth" aria-describedby="basic-addon-name" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your place of birth.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Date Of Birth <span style="color:red;">*</span></label>
<input type="date" id="date_of_birth" name="date_of_birth" class="form-control flatpickr-basic" placeholder="input place of birth" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your place of birth.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Gender <span style="color:red;">*</span></label>
<div class="form-check my-50">
<input type="radio" id="validationRadio3" name="gender" class="form-check-input" value="Male" required="">
<label class="form-check-label" for="validationRadio3">Male</label>
</div>
<div class="form-check">
<input type="radio" id="validationRadio4" name="gender" class="form-check-input" value="Female" required="">
<label class="form-check-label" for="validationRadio4">Female</label>
</div>
</div>
<div class="mb-1">
<label class="form-label" for="select-country1">Province <span style="color:red;">*</span></label>
<div class="position-relative">
<div class="position-relative"><select class="form-select select2 select2-hidden-accessible" name="province" id="province" required="" tabindex="-1" aria-hidden="true" data-select2-id="province">
<option value="" data-select2-id="120">Select Province</option>
<option value="ACEH">ACEH</option>
<option value="SUMATERA UTARA">SUMATERA UTARA</option>
<option value="SUMATERA BARAT">SUMATERA BARAT</option>
<option value="RIAU">RIAU</option>
<option value="JAMBI">JAMBI</option>
<option value="SUMATERA SELATAN">SUMATERA SELATAN</option>
<option value="BENGKULU">BENGKULU</option>
<option value="LAMPUNG">LAMPUNG</option>
<option value="KEPULAUAN BANGKA BELITUNG">KEPULAUAN BANGKA BELITUNG</option>
<option value="KEPULAUAN RIAU">KEPULAUAN RIAU</option>
<option value="DKI JAKARTA">DKI JAKARTA</option>
<option value="JAWA BARAT">JAWA BARAT</option>
<option value="JAWA TENGAH">JAWA TENGAH</option>
<option value="DAERAH ISTIMEWA YOGYAKARTA">DAERAH ISTIMEWA YOGYAKARTA</option>
<option value="JAWA TIMUR">JAWA TIMUR</option>
<option value="BANTEN">BANTEN</option>
<option value="BALI">BALI</option>
<option value="NUSA TENGGARA BARAT">NUSA TENGGARA BARAT</option>
<option value="NUSA TENGGARA TIMUR">NUSA TENGGARA TIMUR</option>
<option value="KALIMANTAN BARAT">KALIMANTAN BARAT</option>
<option value="KALIMANTAN TENGAH">KALIMANTAN TENGAH</option>
<option value="KALIMANTAN SELATAN">KALIMANTAN SELATAN</option>
<option value="KALIMANTAN TIMUR">KALIMANTAN TIMUR</option>
<option value="KALIMANTAN UTARA">KALIMANTAN UTARA</option>
<option value="SULAWESI UTARA">SULAWESI UTARA</option>
<option value="SULAWESI TENGAH">SULAWESI TENGAH</option>
<option value="SULAWESI SELATAN">SULAWESI SELATAN</option>
<option value="SULAWESI TENGGARA">SULAWESI TENGGARA</option>
<option value="GORONTALO">GORONTALO</option>
<option value="SULAWESI BARAT">SULAWESI BARAT</option>
<option value="MALUKU">MALUKU</option>
<option value="MALUKU UTARA">MALUKU UTARA</option>
<option value="PAPUA">PAPUA</option>
<option value="PAPUA BARAT">PAPUA BARAT</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="119" style="width: 685px;"><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-province-container"><span class="select2-selection__rendered" id="select2-province-container" role="textbox"
aria-readonly="true"><span class="select2-selection__placeholder">Select value</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 class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please select your package</div>
</div>
<div class="mb-1">
<label class="form-label" for="select-country1">City <span style="color:red;">*</span></label>
<div class="position-relative">
<div class="position-relative"><select class="form-select select2 select2-hidden-accessible" name="city" id="city" required="" tabindex="-1" aria-hidden="true" data-select2-id="city">
<option value="" data-select2-id="123">Select City</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="122" style="width: 685px;"><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-city-container"><span class="select2-selection__rendered" id="select2-city-container" role="textbox"
aria-readonly="true"><span class="select2-selection__placeholder">Select value</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 class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please select your package</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Address <span style="color:red;">*</span></label>
<textarea id="address" name="address" class="form-control" placeholder="input address" required="" style="height: 100px"></textarea>
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your disease history.</div>
</div>
</div>
<div class="col-md-6">
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Phone <span style="color:red;">*</span></label>
<input type="text" id="phone" name="phone" class="form-control" placeholder="input phone" onkeypress="return onlyNumberKey(event)" aria-describedby="basic-addon-name" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your phone.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Email <span style="color:red;">*</span></label>
<input type="email" id="email" name="email" class="form-control" placeholder="input email" aria-describedby="basic-addon-name" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your email.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Employment <span style="color:red;">*</span></label>
<input type="text" id="employment" name="employment" class="form-control" placeholder="input employment" aria-describedby="basic-addon-name" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your employment.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Institution <span style="color:red;">*</span></label>
<input type="text" id="institution" name="institution" class="form-control" placeholder="input institution" aria-describedby="basic-addon-name" required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your institution.</div>
</div>
<div class="mb-1">
<label class="form-label">Select your answer <span style="color:red;">* </span></label>
<div class="position-relative">
<div class="position-relative"><select class="form-select select2 select2-hidden-accessible" name="status_company" id="status_company" required="" tabindex="-1" aria-hidden="true" data-select2-id="status_company">
<option value="" data-select2-id="128">Select answer</option>
<option value="company">Company</option>
<option value="invidual">Invidual</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="127" style="width: 685px;"><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-status_company-container"><span class="select2-selection__rendered" id="select2-status_company-container"
role="textbox" aria-readonly="true"><span class="select2-selection__placeholder">Select value</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 class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please select your answer</div>
</div>
<div class="mb-1" id="vcompany" style="display: none;">
<label class="form-label" for="basic-addon-name">Company Name <span style="color:red;">*</span></label>
<input type="text" id="company_name" name="company_name" class="form-control" placeholder="Input company name" aria-label="Input company name" aria-describedby="basic-addon-name">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your company name.</div>
</div>
<div class="mb-1" id="vcompany_add" style="display: none;">
<label class="form-label" for="basic-addon-name">Company Address <span style="color:red;">*</span></label>
<textarea id="company_address" name="company_address" class="form-control" placeholder="input company address" style="height: 100px"></textarea>
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your company address.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Identity Number <span style="color:red;">*</span></label>
<input type="text" id="identity_number" name="identity_number" class="form-control" placeholder="input identity number" aria-label="identity number" aria-describedby="basic-addon-name" onkeypress="return onlyNumberKey(event)"
required="">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter your identity number.</div>
</div>
<div class="mb-1">
<label class="form-label" for="basic-addon-name">Where did you hear about Erol Perkasa Mandiri ? <span style="color:red;">*</span></label>
<div class="position-relative">
<div class="position-relative"><select class="form-select select2 select2-hidden-accessible" name="reference" id="reference" required="" tabindex="-1" aria-hidden="true" data-select2-id="reference">
<option value="Internet" selected="" data-select2-id="142">Internet (Website, etc)</option>
<option value="Ads">Ads</option>
<option value="Facebook">Facebook</option>
<option value="Instagram">Instagram</option>
<option value="Tiktok">Tiktok</option>
<option value="Twitter">Twitter</option>
<option value="Youtube">Youtube</option>
<option value="Friends">Friends</option>
<option value="Family">Family</option>
<option value="Community">Community</option>
<option value="flyer">Flyer or E-Flyer</option>
<option value="others">Others</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="141" style="width: 685px;"><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-reference-container"><span class="select2-selection__rendered" id="select2-reference-container" role="textbox"
aria-readonly="true" title="Internet (Website, etc)">Internet (Website, etc)</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 class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please select reference.</div>
</div>
<div class="mb-1" id="othref" style="display: none;">
<label class="form-label" for="basic-addon-name" id="lbloth">Other <span style="color:red;">*</span></label>
<input type="text" id="reference_other" name="reference_other" class="form-control" placeholder="input other how do you know about this event" aria-label="reference_other" aria-describedby="basic-addon-name">
<div class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please enter others how do yo know about thsi event.</div>
</div>
<input type="hidden" name="tmpfile" id="tmpfile" style="display: none;">
<input type="hidden" name="tmpekt" id="tmpekt">
<input type="hidden" name="tmpcpr" id="tmpcpr" value="0">
<div class="mb-1">
<label class="form-label" for="select-country1">Payment methods <span style="color:red;">*</span></label>
<div class="position-relative">
<div class="position-relative"><select class="form-select select2 select2-hidden-accessible" name="payment_method" id="payment_method" required="" tabindex="-1" aria-hidden="true" data-select2-id="payment_method">
<option value="">Select Payment methods</option>
<option value="transfer">Transfer Bank</option>
<option value="va" selected="" data-select2-id="147">Virtual Account</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="146" style="width: 685px;"><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-payment_method-container"><span class="select2-selection__rendered" id="select2-payment_method-container"
role="textbox" aria-readonly="true" title="Virtual Account">Virtual Account</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 class="valid-feedback">Looks good!</div>
<div class="invalid-feedback">Please select Payment methods</div>
</div>
<div class="mb-1">
<label for="customFile1" class="form-label" style="font-size:25px;">Total Price Rp.</label>
<label class="form-label" style="font-size:30px;font-weight:600" id="lbl_harga">0 </label>
</div>
</div>
</div>
<button type="submit" id="btnsubmit" style="float:right;margin: 20px;" class="btn btn-primary waves-effect waves-float waves-light">Submit Data</button>
</div>
</div>
</div>
</div>
</section>
</form>Text Content
* EROL PERKASA MANDIRI FORM REGISTRATION 1. Website 2. Form Registration EROL PERKASA MANDIRI EVENT * Select Event Event Erol Select value Looks good! Please select your package Full Name * Looks good! Please enter your fullname. Nick Name * Looks good! Please enter your nickname. Place of Birth * Looks good! Please enter your place of birth. Date Of Birth * Looks good! Please enter your place of birth. Gender * Male Female Province * Select Province ACEH SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEPULAUAN BANGKA BELITUNG KEPULAUAN RIAU DKI JAKARTA JAWA BARAT JAWA TENGAH DAERAH ISTIMEWA YOGYAKARTA JAWA TIMUR BANTEN BALI NUSA TENGGARA BARAT NUSA TENGGARA TIMUR KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA GORONTALO SULAWESI BARAT MALUKU MALUKU UTARA PAPUA PAPUA BARAT Select value Looks good! Please select your package City * Select City Select value Looks good! Please select your package Address * Looks good! Please enter your disease history. Phone * Looks good! Please enter your phone. Email * Looks good! Please enter your email. Employment * Looks good! Please enter your employment. Institution * Looks good! Please enter your institution. Select your answer * Select answer Company Invidual Select value Looks good! Please select your answer Company Name * Looks good! Please enter your company name. Company Address * Looks good! Please enter your company address. Identity Number * Looks good! Please enter your identity number. Where did you hear about Erol Perkasa Mandiri ? * Internet (Website, etc) Ads Facebook Instagram Tiktok Twitter Youtube Friends Family Community Flyer or E-Flyer Others Internet (Website, etc) Looks good! Please select reference. Other * Looks good! Please enter others how do yo know about thsi event. Payment methods * Select Payment methods Transfer Bank Virtual Account Virtual Account Looks good! Please select Payment methods Total Price Rp. 0 Submit Data COPYRIGHT © 2022-2022 Erol Perkasa Mandiri