www.road-side.euro-assist.com Open in urlscan Pro
190.92.171.207  Public Scan

Form analysis
1 forms found in the DOM

POST

<form id="assistanceForm" action="" method="POST" enctype="multipart/form-data">
  <input type="hidden" id="location_url" name="location_url">
  <div class="tab-content">
    <!-- Personal Info -->
    <div id="personal-info" class="tab-pane fade show active">
      <div class="form-group">
        <label for="name">Name <span class="text-danger">*</span></label>
        <input type="text" class="form-control" id="name" name="name" placeholder="Enter your name" required="">
      </div>
      <div class="form-group">
        <label for="phone">Phone <span class="text-danger">*</span></label>
        <input type="tel" class="form-control" id="phone" name="phone" placeholder="Enter your phone number" required="">
      </div>
      <button type="button" class="btn btn-primary btn-block rounded-pill shadow-sm" onclick="showTab('service-info')">Next</button>
    </div>
    <!-- Service Info -->
    <div id="service-info" class="tab-pane fade">
      <div class="form-group">
        <label for="service">Service <span class="text-danger">*</span></label>
        <select class="form-control" id="service" name="service" required="">
          <option value="">--Select Service--</option>
          <option value="Tow Truck">Tow Truck</option>
          <option value="Fuel Delivery">Fuel Delivery</option>
          <option value="Jump Start">Jump Start</option>
          <option value="Flat Tire">Flat Tire</option>
        </select>
      </div>
      <div class="form-group">
        <label for="note">Note</label>
        <textarea class="form-control" id="note" name="note" rows="3" placeholder="Any additional information"></textarea>
      </div>
      <div class="form-group">
        <label for="attachment">Upload Pictures</label>
        <input type="file" class="form-control" id="attachment" name="attachments[]" accept="image/png, image/jpeg" multiple="">
        <small class="form-text text-muted">Accepted formats: .jpg, .png</small>
      </div>
      <input type="checkbox" name="botcheck" class="hidden">
      <button type="button" onclick="getLocationAndSubmit()" class="btn btn-primary btn-block rounded-pill shadow-sm">Submit</button>
    </div>
  </div>
</form>

Text Content

ROADSIDE ASSISTANCE FORM

 * Personal Info
 * Service Info

Name *
Phone *
Next
Service * --Select Service-- Tow Truck Fuel Delivery Jump Start Flat Tire
Note
Upload Pictures Accepted formats: .jpg, .png
Submit