pbc.lifestyles.net Open in urlscan Pro
216.208.222.38  Public Scan

Form analysis
1 forms found in the DOM

Name: form1 — POST incl/process_firstdata_start.php

<form action="incl/process_firstdata_start.php" method="post" name="form1" id="form1">
  <table width="100%" border="0" align="center" cellpadding="2" cellspacing="0" style="background-color:#ffffff; border: 1px solid #CCC">
    <tbody>
      <tr bgcolor="#d5dca3">
        <td colspan="2"><img src="../includes/images/Shop_mobile1.png" border="0" style="float:left;"></td>
      </tr>
      <tr>
        <td colspan="2" height="50">
          <div style="font-family:Verdana, Geneva, sans-serif; font-size:15px; color:#738828; padding:10px"> Lifestyles Membership Renewal </div>
        </td>
      </tr>
      <tr>
        <td colspan="2" style="padding:10px">
          <p>Hello Venus Rieza,</p>
          <p>Please choose a membership option, then click the "Start Payment &gt;" button to start the online renewal process. Please don't close or refresh the browser during process. Thank you!</p>
        </td>
      </tr>
      <tr>
        <td width="22" height="40">&nbsp;</td>
        <td width="868"><strong>Membership Option:</strong></td>
      </tr>
      <tr>
        <td height="50">&nbsp;</td>
        <td>
          <div class="ui-select ui-btn-inline ui-mini">
            <div id="paytype-button" class="ui-btn ui-icon-carat-d ui-btn-icon-right ui-corner-all ui-shadow"><span>Select one</span><select name="paytype" id="paytype" data-mini="true" data-inline="true">
                <option value="">Select one</option>
                <option value="0002PH#750"> Renewal Fee (Tax incl.) - Php 750 </option>
                <option value="3251  ,  3002PH#2000"> Renewal Fee with Insurance (Tax incl.) - Php 2000 </option>
              </select></div>
          </div>
        </td>
      </tr>
      <tr>
        <td height="50">&nbsp;</td>
        <td>
          <div class="ui-btn ui-input-btn ui-corner-all ui-shadow ui-mini">Start Payment &gt;<input type="button" name="btn" id="btn" value="Start Payment >" onclick="submitcheck()" data-mini="true"></div>
        </td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td>
          <p>
            <input type="hidden" name="rowid" id="rowid" value="164199">
            <input type="hidden" name="work" id="work" value="n">
            <input type="hidden" name="test" id="test" value="">
            <input type="hidden" name="officecode" id="officecode" value="PH">
            <input type="hidden" name="email" id="email" value="dondavis_rieza@yahoo.com">
            <input type="hidden" name="fullname" id="fullname" value="Venus Rieza">
            <input type="hidden" name="dist_id" id="dist_id" value="98000287873">
          </p>
          <p>&nbsp; </p>
        </td>
      </tr>
    </tbody>
  </table>
</form>

Text Content

Lifestyles Membership Renewal

Hello Venus Rieza,

Please choose a membership option, then click the "Start Payment >" button to
start the online renewal process. Please don't close or refresh the browser
during process. Thank you!

  Membership Option:  
Select one Select one Renewal Fee (Tax incl.) - Php 750 Renewal Fee with
Insurance (Tax incl.) - Php 2000
 
Start Payment >
 



 


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