steadymotionforwarddeals.com Open in urlscan Pro
2606:4700:3030::ac43:93c3 Public Scan

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Submitted URL:
http://offers-aff-world.com/zvm5ci29
Effective URL:
https://steadymotionforwarddeals.com/bldtcv1aff/checkout/?pub=11559&click_id=703145491&c1=9bf9bfd1-23ce-4fac-9824-55c310c27e40&c2=oXv...
Submission: On February 09 via api (February 9th 2024, 9:53:39 pm UTC) from US — Scanned from US

Form analysis
2 forms found in the DOM

POST

<form id="payment-form" class="checkout-form has-validation-callback" method="post">
  <input type="hidden" name="action" value="checkout">
  <input type="hidden" name="x_amount" value="147.58" data-threeds="amount">
  <input type="hidden" name="x_transaction_id" value="" data-threeds="id">
  <div class="fields">
    <input value="" type="text" name="first_name" data-group="1" placeholder="First Name" required="" data-field="first_name" class="form-control  " data-validation="required">
  </div>
  <div class="fields">
    <input value="" type="text" name="last_name" data-group="1" placeholder="Last Name" required="" data-field="last_name" class="form-control  " data-validation="required">
  </div>
  <div class="fields" style="display: none;">
    <select name="country" class="form-control " id="country" data-group="1" data-state="state" data-field="country">
      <option selected="selected" value="US"
        data-states="{&quot;AL&quot;:&quot;Alabama&quot;,&quot;AK&quot;:&quot;Alaska&quot;,&quot;AZ&quot;:&quot;Arizona&quot;,&quot;AR&quot;:&quot;Arkansas&quot;,&quot;CA&quot;:&quot;California&quot;,&quot;CO&quot;:&quot;Colorado&quot;,&quot;CT&quot;:&quot;Connecticut&quot;,&quot;DE&quot;:&quot;Delaware&quot;,&quot;FL&quot;:&quot;Florida&quot;,&quot;GA&quot;:&quot;Georgia&quot;,&quot;HI&quot;:&quot;Hawaii&quot;,&quot;ID&quot;:&quot;Idaho&quot;,&quot;IL&quot;:&quot;Illinois&quot;,&quot;IN&quot;:&quot;Indiana&quot;,&quot;IA&quot;:&quot;Iowa&quot;,&quot;KS&quot;:&quot;Kansas&quot;,&quot;KY&quot;:&quot;Kentucky&quot;,&quot;LA&quot;:&quot;Lousiana&quot;,&quot;ME&quot;:&quot;Maine&quot;,&quot;MD&quot;:&quot;Maryland&quot;,&quot;MA&quot;:&quot;Massachusetts&quot;,&quot;MI&quot;:&quot;Michigan&quot;,&quot;MN&quot;:&quot;Minnesota&quot;,&quot;MS&quot;:&quot;Mississippi&quot;,&quot;MO&quot;:&quot;Missouri&quot;,&quot;MT&quot;:&quot;Montana&quot;,&quot;NE&quot;:&quot;Nebraska&quot;,&quot;NV&quot;:&quot;Nevada&quot;,&quot;NH&quot;:&quot;New Hampshire&quot;,&quot;NJ&quot;:&quot;New Jersey&quot;,&quot;NM&quot;:&quot;New Mexico&quot;,&quot;NY&quot;:&quot;New York&quot;,&quot;NC&quot;:&quot;North Carolina&quot;,&quot;ND&quot;:&quot;North Dakota&quot;,&quot;OH&quot;:&quot;Ohio&quot;,&quot;OK&quot;:&quot;Oklahoma&quot;,&quot;OR&quot;:&quot;Oregon&quot;,&quot;PA&quot;:&quot;Pennsylvania&quot;,&quot;RI&quot;:&quot;Rhode Island&quot;,&quot;SC&quot;:&quot;South Carolina&quot;,&quot;SD&quot;:&quot;South Dakota&quot;,&quot;TN&quot;:&quot;Tennessee&quot;,&quot;TX&quot;:&quot;Texas&quot;,&quot;UT&quot;:&quot;Utah&quot;,&quot;VT&quot;:&quot;Vermont&quot;,&quot;VA&quot;:&quot;Virginia&quot;,&quot;WA&quot;:&quot;Washington&quot;,&quot;WV&quot;:&quot;West Virginia&quot;,&quot;WI&quot;:&quot;Wisconsin&quot;,&quot;WY&quot;:&quot;Wyoming&quot;,&quot;DC&quot;:&quot;Washington, DC&quot;}">
        United States</option>
    </select>
  </div>
  <div class="fields">
    <input value="" type="tel" pattern="^[0-9]{5}" name="zip" data-group="1" placeholder="Zip / Postal" required="" data-field="zip" class="form-control  " data-validation="required custom" data-validation-regexp="^[0-9]{5}" maxlength="5">
  </div>
  <div class="fields">
    <input value="" type="text" pattern="^(?=.*[0-9])(?=.*[a-zA-Z])(?=.*[ ])([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$" name="address" data-group="1" placeholder="Address" required="" data-field="address" class="form-control  "
      data-validation="required custom" data-validation-regexp="^(?=.*[0-9])(?=.*[a-zA-Z])(?=.*[ ])([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$">
  </div>
  <div class="fields">
    <input value="" type="text" pattern="^([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$" name="address_2" data-group="1" placeholder="Apt / Suite #" data-field="address_2" class="form-control  " data-validation="custom"
      data-validation-regexp="^([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$" data-validation-optional="true">
  </div>
  <div class="fields">
    <input value="" type="text" pattern="^[a-zA-Z. ]{3,}$" name="city" data-group="1" placeholder="City" required="" data-field="city" class="form-control  " data-validation="required custom" data-validation-regexp="^[a-zA-Z. ]{3,}$">
  </div>
  <div class="fields">
    <select name="state" required="" class="form-control   " data-field="state" data-group="1" id="state" data-default="" placeholder="State" data-validation="required">
      <option value="" selected="selected">Select State</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>
      <option value="FL">Florida</option>
      <option value="GA">Georgia</option>
      <option value="HI">Hawaii</option>
      <option value="ID">Idaho</option>
      <option value="IL">Illinois</option>
      <option value="IN">Indiana</option>
      <option value="IA">Iowa</option>
      <option value="KS">Kansas</option>
      <option value="KY">Kentucky</option>
      <option value="LA">Lousiana</option>
      <option value="ME">Maine</option>
      <option value="MD">Maryland</option>
      <option value="MA">Massachusetts</option>
      <option value="MI">Michigan</option>
      <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>
      <option value="NC">North Carolina</option>
      <option value="ND">North Dakota</option>
      <option value="OH">Ohio</option>
      <option value="OK">Oklahoma</option>
      <option value="OR">Oregon</option>
      <option value="PA">Pennsylvania</option>
      <option value="RI">Rhode Island</option>
      <option value="SC">South Carolina</option>
      <option value="SD">South Dakota</option>
      <option value="TN">Tennessee</option>
      <option value="TX">Texas</option>
      <option value="UT">Utah</option>
      <option value="VT">Vermont</option>
      <option value="VA">Virginia</option>
      <option value="WA">Washington</option>
      <option value="WV">West Virginia</option>
      <option value="WI">Wisconsin</option>
      <option value="WY">Wyoming</option>
      <option value="DC">Washington, DC</option>
    </select>
  </div>
  <div class="fields">
    <input value="" type="email" name="email" data-group="1" placeholder="Email Address" required="" data-field="email" class="form-control  " data-validation="required email">
  </div>
  <div class="fields">
    <input value="" type="tel" name="phone" data-group="1" placeholder="Phone Number" required="" data-field="phone" class="form-control  " data-validation="required" maxlength="14">
  </div>
  <div id="shipAddress">
    <div style="padding-bottom: 15px; text-align: center;">
      <div class="card_logos">
        <img class="ccLogos" src="/assets/images/visaCCLogo.png" alt="">
        <img class="ccLogos" src="/assets/images/masterCCLogo.png" alt="">
      </div>
    </div>
  </div>
  <div class="fields">
    <input type="tel" tabindex="1" class="formfield ib" name="ccnum" id="ccnum" required="" value="" pattern="(\D*\d){16,}" placeholder="Credit Card #" data-validation="required custom" data-validation-regexp="(\D*\d){16,}" maxlength="19">
    <input type="hidden" data-threeds="pan" id="3ds_ccnum" value="">
  </div>
  <div class="fields card-fields">
    <select tabindex="2" style=" padding: 5px;" id="ccexpmonth" name="exp_month" class="required expmonth" required="" data-threeds="month" data-validation="required">
      <option value="">Month</option>
      <option value="01">(01) January</option>
      <option value="02">(02) February</option>
      <option value="03">(03) March</option>
      <option value="04">(04) April</option>
      <option value="05">(05) May</option>
      <option value="06">(06) June</option>
      <option value="07">(07) July</option>
      <option value="08">(08) August</option>
      <option value="09">(09) September</option>
      <option value="10">(10) October</option>
      <option value="11">(11) November</option>
      <option value="12">(12) December</option>
    </select>
  </div>
  <div class="fields card-fields">
    <select tabindex="3" style=" padding: 5px;" id="ccexpyear" name="exp_year" required="" data-threeds="year" data-validation="required">
      <option value="">Year</option>
      <option value="24">2024</option>
      <option value="25">2025</option>
      <option value="26">2026</option>
      <option value="27">2027</option>
      <option value="28">2028</option>
      <option value="29">2029</option>
      <option value="30">2030</option>
      <option value="31">2031</option>
      <option value="32">2032</option>
      <option value="33">2033</option>
      <option value="34">2034</option>
      <option value="35">2035</option>
      <option value="36">2036</option>
      <option value="37">2037</option>
      <option value="38">2038</option>
      <option value="39">2039</option>
      <option value="40">2040</option>
      <option value="41">2041</option>
      <option value="42">2042</option>
      <option value="43">2043</option>
      <option value="44">2044</option>
    </select>
  </div>
  <div class="fields">
    <input type="tel" tabindex="4" class="formfield short" id="cvv" name="cvv" placeholder="CVV" pattern="(\D*\d){3}" title="3 Digit Security Code" value="" required="" data-validation="required custom" data-validation-regexp="(\D*\d){3}"
      maxlength="3">
    <!--<a href="#vmodal" data-modal-url="/bldtcv1aff/cvv/"><img src='/assets/images/cvv-img.png' style='vertical-align: middle;  margin-left: 12px; width: 84px;'></a>-->
  </div>
  <div class="sameAsShipping">
    <label>
      <input type="checkbox" name="billingSameAsShipping" value="yes" checked="" onclick="$('#billAddress').slideToggle();"> Same Shipping and Billing Address </label>
  </div>
  <div id="billAddress">
    <div style="padding-bottom: 15px; text-align: center; font-size: 18px; font-weight: bold;">Enter your billing information</div>
    <div class="fields">
      <label> First Name: </label>
      <input value="" type="text" name="billing_first_name" data-group="2" placeholder="First Name" data-field="billing_first_name" class="form-control  ">
    </div>
    <div class="fields">
      <label> Last Name: </label>
      <input value="" type="text" name="billing_last_name" data-group="2" placeholder="Last Name" data-field="billing_last_name" class="form-control  ">
    </div>
    <div class="fields" style="display: none;">
      <label> Country: </label>
      <select name="billing_country" class="form-control " id="billing_country" data-group="2" data-state="billing_state" data-field="billing_country">
        <option selected="selected" value="US"
          data-states="{&quot;AL&quot;:&quot;Alabama&quot;,&quot;AK&quot;:&quot;Alaska&quot;,&quot;AZ&quot;:&quot;Arizona&quot;,&quot;AR&quot;:&quot;Arkansas&quot;,&quot;CA&quot;:&quot;California&quot;,&quot;CO&quot;:&quot;Colorado&quot;,&quot;CT&quot;:&quot;Connecticut&quot;,&quot;DE&quot;:&quot;Delaware&quot;,&quot;FL&quot;:&quot;Florida&quot;,&quot;GA&quot;:&quot;Georgia&quot;,&quot;HI&quot;:&quot;Hawaii&quot;,&quot;ID&quot;:&quot;Idaho&quot;,&quot;IL&quot;:&quot;Illinois&quot;,&quot;IN&quot;:&quot;Indiana&quot;,&quot;IA&quot;:&quot;Iowa&quot;,&quot;KS&quot;:&quot;Kansas&quot;,&quot;KY&quot;:&quot;Kentucky&quot;,&quot;LA&quot;:&quot;Lousiana&quot;,&quot;ME&quot;:&quot;Maine&quot;,&quot;MD&quot;:&quot;Maryland&quot;,&quot;MA&quot;:&quot;Massachusetts&quot;,&quot;MI&quot;:&quot;Michigan&quot;,&quot;MN&quot;:&quot;Minnesota&quot;,&quot;MS&quot;:&quot;Mississippi&quot;,&quot;MO&quot;:&quot;Missouri&quot;,&quot;MT&quot;:&quot;Montana&quot;,&quot;NE&quot;:&quot;Nebraska&quot;,&quot;NV&quot;:&quot;Nevada&quot;,&quot;NH&quot;:&quot;New Hampshire&quot;,&quot;NJ&quot;:&quot;New Jersey&quot;,&quot;NM&quot;:&quot;New Mexico&quot;,&quot;NY&quot;:&quot;New York&quot;,&quot;NC&quot;:&quot;North Carolina&quot;,&quot;ND&quot;:&quot;North Dakota&quot;,&quot;OH&quot;:&quot;Ohio&quot;,&quot;OK&quot;:&quot;Oklahoma&quot;,&quot;OR&quot;:&quot;Oregon&quot;,&quot;PA&quot;:&quot;Pennsylvania&quot;,&quot;RI&quot;:&quot;Rhode Island&quot;,&quot;SC&quot;:&quot;South Carolina&quot;,&quot;SD&quot;:&quot;South Dakota&quot;,&quot;TN&quot;:&quot;Tennessee&quot;,&quot;TX&quot;:&quot;Texas&quot;,&quot;UT&quot;:&quot;Utah&quot;,&quot;VT&quot;:&quot;Vermont&quot;,&quot;VA&quot;:&quot;Virginia&quot;,&quot;WA&quot;:&quot;Washington&quot;,&quot;WV&quot;:&quot;West Virginia&quot;,&quot;WI&quot;:&quot;Wisconsin&quot;,&quot;WY&quot;:&quot;Wyoming&quot;,&quot;DC&quot;:&quot;Washington, DC&quot;}">
          United States</option>
      </select>
    </div>
    <div class="fields">
      <label> Zip: </label>
      <input value="" type="tel" name="billing_zip" data-group="2" placeholder="Zip / Postal" data-field="billing_zip" class="form-control  " maxlength="5">
    </div>
    <div class="fields">
      <label> Address: </label>
      <input value="" type="text" name="billing_address" data-group="2" placeholder="Address" data-field="billing_address" class="form-control  ">
    </div>
    <div class="fields">
      <label> Address 2: </label>
      <input value="" type="text" name="billing_address_2" data-group="2" placeholder="Apt / Suite #" data-field="billing_address_2" class="form-control  ">
    </div>
    <div class="fields">
      <label> City: </label>
      <input value="" type="text" name="billing_city" data-group="2" placeholder="City" data-field="billing_city" class="form-control  ">
    </div>
    <div class="fields">
      <label> State: </label>
      <select name="billing_state" class="form-control   " data-field="state" data-group="2" id="billing_state" data-default="" placeholder="State">
        <option value="" selected="selected">Select State</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>
        <option value="FL">Florida</option>
        <option value="GA">Georgia</option>
        <option value="HI">Hawaii</option>
        <option value="ID">Idaho</option>
        <option value="IL">Illinois</option>
        <option value="IN">Indiana</option>
        <option value="IA">Iowa</option>
        <option value="KS">Kansas</option>
        <option value="KY">Kentucky</option>
        <option value="LA">Lousiana</option>
        <option value="ME">Maine</option>
        <option value="MD">Maryland</option>
        <option value="MA">Massachusetts</option>
        <option value="MI">Michigan</option>
        <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>
        <option value="NC">North Carolina</option>
        <option value="ND">North Dakota</option>
        <option value="OH">Ohio</option>
        <option value="OK">Oklahoma</option>
        <option value="OR">Oregon</option>
        <option value="PA">Pennsylvania</option>
        <option value="RI">Rhode Island</option>
        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
        <option value="TX">Texas</option>
        <option value="UT">Utah</option>
        <option value="VT">Vermont</option>
        <option value="VA">Virginia</option>
        <option value="WA">Washington</option>
        <option value="WV">West Virginia</option>
        <option value="WI">Wisconsin</option>
        <option value="WY">Wyoming</option>
        <option value="DC">Washington, DC</option>
      </select>
    </div>
  </div>
  <div class="fields">
    <div class="disclaimer" style="padding: 10px 10px 0 10px;"> By submitting, you affirm to have read and agreed to our
      <a href="#vmodal" data-modal-url="/bldtcv1aff/terms/" style="color:inherit;text-decoration:underline; cursor: pointer;">Terms &amp; Conditions</a>. </div>
  </div>
  <div class="fields submit">
    <button type="submit" class="submit" id="form-submit">Complete Order</button>
  </div>
  <p class="secure-256 center">
    <img src="/assets/images/lock-icon.png" alt=""> Secure 256 Bit Encrypted Connection
  </p>
  <p class="center">
    <img src="/assets/images/secureicons.jpg" alt=""><br>
    <img src="https://vaultximg.com/wp-content/uploads/2023/05/checkout-seal-bottom-v1.png">
  </p>
</form>

POST /

<form method="post" class="update-shipping-form has-validation-callback" action="/">
  <input type="hidden" name="action" value="prospect">
  <div class="shipping-fields">
    <label> First Name: </label>
    <div class="shipping-field">
      <input value="" type="text" name="first_name" data-group="1" placeholder="First Name" required="" data-field="first_name" class="form-control  " data-validation="required">
    </div>
  </div>
  <div class="shipping-fields">
    <label> Last Name: </label>
    <div class="shipping-field">
      <input value="" type="text" name="last_name" data-group="1" placeholder="Last Name" required="" data-field="last_name" class="form-control  " data-validation="required">
    </div>
  </div>
  <div class="shipping-fields">
    <label> Country: </label>
    <div class="shipping-field">
      <select name="country" class="form-control " id="country" data-group="1" data-state="state" data-field="country">
        <option selected="selected" value="US"
          data-states="{&quot;AL&quot;:&quot;Alabama&quot;,&quot;AK&quot;:&quot;Alaska&quot;,&quot;AZ&quot;:&quot;Arizona&quot;,&quot;AR&quot;:&quot;Arkansas&quot;,&quot;CA&quot;:&quot;California&quot;,&quot;CO&quot;:&quot;Colorado&quot;,&quot;CT&quot;:&quot;Connecticut&quot;,&quot;DE&quot;:&quot;Delaware&quot;,&quot;FL&quot;:&quot;Florida&quot;,&quot;GA&quot;:&quot;Georgia&quot;,&quot;HI&quot;:&quot;Hawaii&quot;,&quot;ID&quot;:&quot;Idaho&quot;,&quot;IL&quot;:&quot;Illinois&quot;,&quot;IN&quot;:&quot;Indiana&quot;,&quot;IA&quot;:&quot;Iowa&quot;,&quot;KS&quot;:&quot;Kansas&quot;,&quot;KY&quot;:&quot;Kentucky&quot;,&quot;LA&quot;:&quot;Lousiana&quot;,&quot;ME&quot;:&quot;Maine&quot;,&quot;MD&quot;:&quot;Maryland&quot;,&quot;MA&quot;:&quot;Massachusetts&quot;,&quot;MI&quot;:&quot;Michigan&quot;,&quot;MN&quot;:&quot;Minnesota&quot;,&quot;MS&quot;:&quot;Mississippi&quot;,&quot;MO&quot;:&quot;Missouri&quot;,&quot;MT&quot;:&quot;Montana&quot;,&quot;NE&quot;:&quot;Nebraska&quot;,&quot;NV&quot;:&quot;Nevada&quot;,&quot;NH&quot;:&quot;New Hampshire&quot;,&quot;NJ&quot;:&quot;New Jersey&quot;,&quot;NM&quot;:&quot;New Mexico&quot;,&quot;NY&quot;:&quot;New York&quot;,&quot;NC&quot;:&quot;North Carolina&quot;,&quot;ND&quot;:&quot;North Dakota&quot;,&quot;OH&quot;:&quot;Ohio&quot;,&quot;OK&quot;:&quot;Oklahoma&quot;,&quot;OR&quot;:&quot;Oregon&quot;,&quot;PA&quot;:&quot;Pennsylvania&quot;,&quot;RI&quot;:&quot;Rhode Island&quot;,&quot;SC&quot;:&quot;South Carolina&quot;,&quot;SD&quot;:&quot;South Dakota&quot;,&quot;TN&quot;:&quot;Tennessee&quot;,&quot;TX&quot;:&quot;Texas&quot;,&quot;UT&quot;:&quot;Utah&quot;,&quot;VT&quot;:&quot;Vermont&quot;,&quot;VA&quot;:&quot;Virginia&quot;,&quot;WA&quot;:&quot;Washington&quot;,&quot;WV&quot;:&quot;West Virginia&quot;,&quot;WI&quot;:&quot;Wisconsin&quot;,&quot;WY&quot;:&quot;Wyoming&quot;,&quot;DC&quot;:&quot;Washington, DC&quot;}">
          United States</option>
      </select>
    </div>
  </div>
  <div class="shipping-fields">
    <label> Zip: </label>
    <div class="shipping-field">
      <input value="" type="tel" pattern="^[0-9]{5}" name="zip" data-group="1" placeholder="Zip / Postal" required="" data-field="zip" class="form-control  " data-validation="required custom" data-validation-regexp="^[0-9]{5}" maxlength="5">
    </div>
  </div>
  <div class="shipping-fields">
    <label> Address: </label>
    <div class="shipping-field">
      <input value="" type="text" pattern="^(?=.*[0-9])(?=.*[a-zA-Z])(?=.*[ ])([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$" name="address" data-group="1" placeholder="Address" required="" data-field="address" class="form-control  "
        data-validation="required custom" data-validation-regexp="^(?=.*[0-9])(?=.*[a-zA-Z])(?=.*[ ])([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$">
    </div>
  </div>
  <div class="shipping-fields">
    <label> Address 2: </label>
    <div class="shipping-field">
      <input value="" type="text" pattern="^([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$" name="address_2" data-group="1" placeholder="Apt / Suite #" data-field="address_2" class="form-control  " data-validation="custom"
        data-validation-regexp="^([a-zA-Z0-9'\/\-\. #@%&amp;`´‘’]+)$" data-validation-optional="true">
    </div>
  </div>
  <div class="shipping-fields">
    <label> City: </label>
    <div class="shipping-field">
      <input value="" type="text" pattern="^[a-zA-Z. ]{3,}$" name="city" data-group="1" placeholder="City" required="" data-field="city" class="form-control  " data-validation="required custom" data-validation-regexp="^[a-zA-Z. ]{3,}$">
    </div>
  </div>
  <div class="shipping-fields">
    <label> State: </label>
    <div class="shipping-field">
      <select name="state" required="" class="form-control   " data-field="state" data-group="1" id="state" data-default="" placeholder="State" data-validation="required">
        <option value="">Select a State</option>
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