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1 forms found in the DOM

POST funcs/capture_data.php?type=sub

<form class="msForm" action="funcs/capture_data.php?type=sub" id="formSubRecap" method="POST">
  <div class="form-header-container"> Join Today <span id="form-free">For Free!</span>
  </div>
  <!-- first row -->
  <div class="form-block-row">
    <div class="form-block-group-left">
      <label for="firstname" class="form-block__form__label color-fff fs16 fw100"> First Name: </label>
      <input type="text" name="firstname" id="firstname" class="form-block-input color-tertiary fs18" value="" maxlength="2147483647">
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    <div class="form-block-group-right">
      <label for="lastname" class="form-block__form__label color-fff fs16 fw100"> Last Name: </label>
      <input type="text" name="lastname" id="lastname" class="form-block-input color-tertiary fs18" value="" maxlength="2147483647">
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  <!--  End of first row --->
  <!-- second row -->
  <div class="form-block-row">
    <div class="form-block-group-left">
      <label for="email" class="form-block__form__label color-fff fs16 fw100"> Email: </label>
      <input type="text" name="email" id="email" class="form-block-input color-tertiary fs18 xverify_email" value="" onblur="makeOptionsVisible(); getPingPartner(); getGender();">
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    <div class="form-block-group-right">
      <label for="phonenumber" class="form-block__form__label color-fff fs16 fw100"> Phone: </label>
      <input type="text" name="phonenumber" id="phonenumber" class="form-block-input color-tertiary fs18" value="" maxlength="10">
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  <!--  End of second row --->
  <!-- third row -->
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    <div class="form-block-group-right">
      <label for="city" class="form-block__form__label color-fff fs16 fw100"> City: </label>
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  <!--  End of third row --->
  <!-- fourth row -->
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    <div class="form-block-group-left">
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        <option value="">Select</option>
        <option value="AL">Alabama</option>
        <option value="AK">Alaska</option>
        <option value="AZ">Arizona</option>
        <option value="AR">Arkansas</option>
        <option value="CA">California</option>
        <option value="CO">Colorado</option>
        <option value="CT">Connecticut</option>
        <option value="DE">Delaware</option>
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        <option value="HI">Hawaii</option>
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        <option value="MN">Minnesota</option>
        <option value="MS">Mississippi</option>
        <option value="MO">Missouri</option>
        <option value="MT">Montana</option>
        <option value="NE">Nebraska</option>
        <option value="NV">Nevada</option>
        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
        <option value="NY">New York</option>
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        <option value="OK">Oklahoma</option>
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        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
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  <!-- second row -->
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      <!-- Birth Month -->
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        <option value="8">August</option>
        <option value="9">September</option>
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        <option value="14">14</option>
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        <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>
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      <!-- End of Birth Day -->
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        <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>
      </select>
      <!-- End of Birth Year -->
    </div>
    <div class="form-block-group-right">
      <label for="gender" class="form-block__form__label color-fff fs16 fw100"> Gender: </label>
      <select name="gender" id="gender" class="form-block-select color-tertiary" style="width:210px; color:#999;" onchange="getGender();">
        <option value="">Select</option>
        <option value="M">Male</option>
        <option value="F">Female</option>
      </select>
    </div>
  </div>
  <!--  End of second row --->
  <input type="hidden" id="source" name="source" value="025_D_0_BL16L30124F13294_0_1215_00_SUB_0">
  <input type="hidden" id="aibsource" name="aibsource" value="025_D_0_BL16L30124F13294_0_1215_00_SUB_0">
  <input type="hidden" name="siteRandomId" value="BL16L30124F13294">
  <!-- dynamic coregs and terms -->
  <div class="form-block__form__opt-in terms_dynamic_coreg">
    <input type="checkbox" name="chk_terms" id="chk_terms" style="" title="Opt-In">
    <div class="opt-in-detail font-fam-primary fs12 color-fff" style="color: #222;"> By checking this box, you agree to our <a href="https://www.myshopdiscounts.com/terms-and-conditions" target="_blank">Terms of Service</a> and
      <a href="https://www.myshopdiscounts.com/privacy-policy" target="_blank">Privacy Policy</a> and agree to receive daily newsletters and promotions via email from MyShopDiscounts and CouponCartDaily. </div>
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      <script type="text/javascript" src="//www.offerfwd.net/oi/a/29263343.js"></script>
      <style type="text/css">
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      <div id="oi_main_div" style="display:none"></div>
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    <div class="g-recaptcha" data-sitekey="6LeeWXUUAAAAAAOB1IaGtNhdHCqCN_6PQE12d4iH" data-callback="getRecap" data-size="invisible">
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  <div class="signup-banner-container">
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        <div id="processing-image" style="display:none; z-index: 75; margin-top: 10px; margin-bottom: 10px; text-align: center;">
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</form>

Text Content

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State: Select
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ZipCode:
Date of Birth: Month
JanuaryFebuaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day
12345678910111213141516171819202122232425262728293031 Year
2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910
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agree to receive daily newsletters and promotions via email from MyShopDiscounts
and CouponCartDaily.




 
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