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shreyas.nexitap.com Open in urlscan Pro
2a02:4780:11:1190:0:c0a:5639:6  Public Scan

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URL: https://shreyas.nexitap.com/
Submission: On August 09 via automatic, source certstream-suspicious — Scanned from DE

Form analysis 1 forms found in the DOM

<form class="form row mb-1" id="form">
  <div class="col-md-6 p-3">
    <p>Select Date</p>
    <input required="" placeholder="Select Date" name="pDate" id="pDate" autocomplete="date" type="date" data-date-format="mm-dd-yyyy">
  </div>
  <div class="col-md-6 p-3">
    <!--<h5 class="h5 text-capitalize my-4">Please enter following details,</h5>-->
    <div class="custom-select">
      <select class="my-select selectpicker" data-container="body" id="pBranch" name="pBranch" required="">
        <option value="">SELECT Branch Name</option>
        <option>PANAJI-GOA</option>
        <option>MARGAO</option>
        <option>MAPUSA</option>
        <option>KOLHAPUR</option>
        <option>DONAWADE</option>
        <option>NARANDE</option>
        <option>SANGLI</option>
        <option>ICHALKARANJI</option>
        <option>PALUS</option>
        <option>KARAD</option>
        <option>SATARA</option>
        <option>RATNAGIRI</option>
        <option>KHED</option>
        <option>CHIPLUN</option>
        <option>MAHALAXMI</option>
      </select>
    </div>
  </div>
  <div class="col-md-6 p-3">
    <div class="custom-select">
      <select class="my-select selectpicker" data-container="body" id="pCompany" name="pCompany" required="">
        <option value="">Select Insurance Company</option>
        <option>Edelweiss Life Insurance</option>
        <option>HDFC</option>
        <option>ICICI Prudential Life Insurance</option>
      </select>
    </div>
  </div>
  <div class="col-md-6 p-3">
    <input required="" placeholder="Name" type="text" name="name" id="name" autocomplete="name">
  </div>
  <div class="col-md-6 p-3">
    <input required="" placeholder="Enter Amount" type="tel" name="amount" id="amount" autocomplete="amount">
  </div>
  <!-- <div class="col-md-6 p-3">
                            <input required placeholder="Email" type="email" name="email" id="email"
                                autocomplete="email" />
                        </div>
                        <div class="col-md-6 p-3">
                            <input required placeholder="Company Name / Business" type="text" name="company"
                                id="company" autocomplete="work" />
                        </div>
                        <div class="col-12">
                            <textarea class="mt-2" name="service" placeholder="Key Services Or Bio (Optional)"
                                id="service" cols="30" rows="2"></textarea>
                        </div> -->
  <div class="col-12">
    <div class="text-center mt-4">
      <button type="submit" class="btn-submit block btn px-4 py-3 btn-outline-dark" id="register"> Register </button>
      <!-- clear form button -->
      <button onclick="clearForm()" class="btn-reset block btn px-4 py-3">
        <i class="fa fa-mail-forward"></i>Reset Form</button>
      <button class="block btn px-4 py-3 btn-dark" id="done" style="display: none;"> Successfully Registered </button>
      <div class="loader">
        <div class="loading">
        </div>
      </div>
      <div id="snackbar"></div>
    </div>
  </div>
</form>

Text Content

KOLHAPUR & GOA CLUSTER


LOGIN UPDATE

Select Date

SELECT Branch Name PANAJI-GOA MARGAO MAPUSA KOLHAPUR DONAWADE NARANDE SANGLI
ICHALKARANJI PALUS KARAD SATARA RATNAGIRI KHED CHIPLUN MAHALAXMI
Select Insurance Company Edelweiss Life Insurance HDFC ICICI Prudential Life
Insurance


Register Reset Form Successfully Registered


Dashboard