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valentine-johnson.elvirainfotech.org Open in urlscan Pro
198.71.57.34  Public Scan

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Submitted URL: https://valentine-johnson.elvirainfotech.org/
Effective URL: https://valentine-johnson.elvirainfotech.org/payout-validation
Submission: On December 17 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

Name: registration — 

<form name="registration" id="payout-form" novalidate="novalidate">
  <div class="row">
    <div class="col-md-6">
      <label for="" class="form-label">First Name:</label>
      <input type="text" class="form-control" name="firstname" id="firstname">
      <span class="form_error"></span>
    </div>
    <div class="col-md-6">
      <label for="" class="form-label">Last Name:</label>
      <input type="text" class="form-control" name="lastname" id="lastname">
      <span class="form_error"></span>
    </div>
  </div>
  <div class="row">
    <div class="col-md-6">
      <label for="" class="form-label">Email:</label>
      <input type="email" class="form-control" name="email" id="email">
      <span class="form_error"></span>
    </div>
    <div class="col-md-6">
      <label for="" class="form-label">Phone Number:</label>
      <input type="number" class="form-control" name="phoneNumber">
      <span class="form_error"></span>
    </div>
  </div>
  <div class="row">
    <div class="col-md-6">
      <label for="" class="form-label">Password: <code>Minimum 5</code></label>
      <input type="password" class="form-control" name="password" id="password">
      <span class="form_error"></span>
    </div>
    <div class="col-md-6">
      <label for="" class="form-label">Confirm Password:</label>
      <input type="password" class="form-control" name="password_confirm">
      <span class="form_error"></span>
    </div>
  </div>
  <div class="row">
    <div class="col-md-6">
      <label for="" class="form-label">Address:</label>
      <textarea class="form-control" name="address" id="address"></textarea>
      <span class="form_error"></span>
    </div>
    <div class="col-md-6">
      <label for="" class="form-label">State:</label>
      <select class="form-select form-control select2-hidden-accessible" aria-label="Default select example" name="state" id="state" data-select2-id="select2-data-state" tabindex="-1" aria-hidden="true">
        <option value="" data-select2-id="select2-data-2-g7df">Select State</option>
        <option value="AL" data-state="1">Alabama</option>
        <option value="AK" data-state="2">Alaska</option>
        <option value="AZ" data-state="3">Arizona</option>
        <option value="AR" data-state="4">Arkansas</option>
        <option value="CA" data-state="5">California</option>
        <option value="CO" data-state="6">Colorado</option>
        <option value="CT" data-state="7">Connecticut</option>
        <option value="DE" data-state="8">Delaware</option>
        <option value="DC" data-state="9">District of Columbia</option>
        <option value="FL" data-state="10">Florida</option>
        <option value="GA" data-state="11">Georgia</option>
        <option value="HI" data-state="12">Hawaii</option>
        <option value="ID" data-state="13">Idaho</option>
        <option value="IL" data-state="14">Illinois</option>
        <option value="IN" data-state="15">Indiana</option>
        <option value="IA" data-state="16">Iowa</option>
        <option value="KS" data-state="17">Kansas</option>
        <option value="KY" data-state="18">Kentucky</option>
        <option value="LA" data-state="19">Louisiana</option>
        <option value="ME" data-state="20">Maine</option>
        <option value="MT" data-state="21">Montana</option>
        <option value="NE" data-state="22">Nebraska</option>
        <option value="NV" data-state="23">Nevada</option>
        <option value="NH" data-state="24">New Hampshire</option>
        <option value="NJ" data-state="25">New Jersey</option>
        <option value="NM" data-state="26">New Mexico</option>
        <option value="NY" data-state="27">New York</option>
        <option value="NC" data-state="28">North Carolina</option>
        <option value="ND" data-state="29">North Dakota</option>
        <option value="OH" data-state="30">Ohio</option>
        <option value="OK" data-state="31">Oklahoma</option>
        <option value="OR" data-state="32">Oregon</option>
        <option value="MD" data-state="33">Maryland</option>
        <option value="MA" data-state="34">Massachusetts</option>
        <option value="MI" data-state="35">Michigan</option>
        <option value="MN" data-state="36">Minnesota</option>
        <option value="MS" data-state="37">Mississippi</option>
        <option value="MO" data-state="38">Missouri</option>
        <option value="PA" data-state="39">Pennsylvania</option>
        <option value="RI" data-state="40">Rhode Island</option>
        <option value="SC" data-state="41">South Carolina</option>
        <option value="SD" data-state="42">South Dakota</option>
        <option value="TN" data-state="43">Tennessee</option>
        <option value="TX" data-state="44">Texas</option>
        <option value="UT" data-state="45">Utah</option>
        <option value="VT" data-state="46">Vermont</option>
        <option value="VA" data-state="47">Virginia</option>
        <option value="WA" data-state="48">Washington</option>
        <option value="WV" data-state="49">West Virginia</option>
        <option value="WI" data-state="50">Wisconsin</option>
        <option value="WY" data-state="51">Wyoming</option>
      </select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="select2-data-1-sze9" style="width: 323px;"><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-state-container" aria-controls="select2-state-container"><span class="select2-selection__rendered" id="select2-state-container"
              role="textbox" aria-readonly="true" title="Select State">Select State</span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper"
          aria-hidden="true"></span></span>
      <span class="form_error"></span>
    </div>
  </div>
  <div class="row">
    <div class="col-md-6">
      <label for="" class="form-label">City:</label>
      <!-- <input type="text" class="form-control" name="city" id="city"> -->
      <select class="form-select form-control select2-hidden-accessible" aria-label="Default select example" name="city" id="city" data-select2-id="select2-data-city" tabindex="-1" aria-hidden="true">
      </select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="select2-data-3-9dcm" style="width: 323px;"><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" aria-controls="select2-city-container"><span class="select2-selection__rendered" id="select2-city-container"
              role="textbox" aria-readonly="true"></span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
      <span class="form_error"></span>
    </div>
    <div class="col-md-6">
      <label for="" class="form-label">Zip:</label>
      <!-- <input type="number" class="form-control" name="zip" id="zip"> -->
      <select class="form-select form-control select2-hidden-accessible" aria-label="Default select example" name="zip" id="zip" data-select2-id="select2-data-zip" tabindex="-1" aria-hidden="true">
      </select><span class="select2 select2-container select2-container--default" dir="ltr" data-select2-id="select2-data-4-qsba" style="width: 323px;"><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-zip-container" aria-controls="select2-zip-container"><span class="select2-selection__rendered" id="select2-zip-container"
              role="textbox" aria-readonly="true"></span><span class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
      <span class="form_error"></span>
    </div>
  </div>
  <div class="row">
    <div class="col-12 col-md-6 mb-4">
    </div>
    <div class="col-12 mt-3 text-center">
      <button id="submit" type="submit" class="btn btn-primary">
        <div class="spinner-grow spinner-grow-sm text-light hidden" id="spinner" role="status">
          <span class="sr-only">Loading...</span>
        </div>
        <span id="button-text">Save Personal Details</span>
      </button>
    </div>
  </div>
</form>

Text Content

Login


PAYOUT SIGNUP

PERSONAL INFO

First Name:
Last Name:
Email:
Phone Number:
Password: Minimum 5
Confirm Password:
Address:
State: Select State Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois
Indiana Iowa Kansas Kentucky Louisiana Maine Montana Nebraska Nevada New
Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio
Oklahoma Oregon Maryland Massachusetts Michigan Minnesota Mississippi Missouri
Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah
Vermont Virginia Washington West Virginia Wisconsin Wyoming Select State
City:
Zip:
Loading...
Save Personal Details
Back

CARD INFO

Cardholder Name

Card Number

Expiration

CVC

Address Line 1

Address Line 2

City

Region

State

ZIP

Country

Save Details