consumertestconnect.com Open in urlscan Pro
52.6.10.150  Public Scan

URL: https://consumertestconnect.com/tacobell
Submission Tags: @phish_report
Submission: On July 15 via api from FI — Scanned from FI

Form analysis 1 forms found in the DOM

POST /flow?uid=d41b59f6-1b7c-4a64-b580-f6cc24928e46

<form id="formSubmit" action="/flow?uid=d41b59f6-1b7c-4a64-b580-f6cc24928e46" method="POST" data-effect="" data-effect-duration="">
  <div id="f1" class="dynamic-form form-step form1 form1-1">
    <div class="row row-spacing" data-row-id="1">
      <div id="col-field-html" class="col html form-field-col-ignored" data-col-id="1" data-autohide="">
        <div id="path-field-html-1-1-1" class="path-dynamic-field">
          <script>
            function initTimer(targetDate, renderFunction) {
              var countDownDate = new Date(targetDate);
              var x = setInterval(function() {
                try {
                  var now = new Date().getTime();
                  // get total seconds between the times
                  var delta = Math.abs(countDownDate - now) / 1000;
                  // calculate (and subtract) whole days
                  var days = Math.floor(delta / 86400);
                  delta -= days * 86400;
                  // calculate (and subtract) whole hours
                  var hours = Math.floor(delta / 3600) % 24;
                  delta -= hours * 3600;
                  // calculate (and subtract) whole minutes
                  var minutes = Math.floor(delta / 60) % 60;
                  delta -= minutes * 60;
                  // what's left is seconds
                  var seconds = delta % 60;
                  renderFunction({
                    days: Math.floor(days),
                    hours: __padLeft(Math.floor(hours)),
                    minutes: __padLeft(Math.floor(minutes)),
                    seconds: __padLeft(Math.floor(seconds))
                  })
                } catch (e) {
                  console.log(e);
                  return 0;
                }
              }, 1000);
            }

            function __padLeft(number) {
              return number <= 9 ? "0" + number : number;
            }
          </script>
          <span id="timer1" class="fs-1 d-block text-center fw-bolder">04:46:54</span>
          <script>
            try {
              initTimer("2024-08-01T05:59:59.000Z", function(t) {
                document.querySelector("#timer1").innerHTML = "" + t.hours + ":" + t.minutes + ":" + t.seconds + "";
              })
            } catch (e) {}
          </script>
          <style>
            #msg1,
            #msg2,
            #timer1,
            #timer2 {
              color: #1D2023 !important;
            }

            .sweep h2 {
              margin-top: 150px !important;
            }

            #msg1 {
              display: block;
              margin-top: 45px;
            }

            #msg2 {
              display: block;
              margin-bottom: 45px;
            }

            #timer2 {
              display: block;
              margin-bottom: 45px;
            }
          </style>
        </div>
        <script>
          document.querySelector('#path-field-html-1-1-1').addEventListener('path-dynamic-field-register', function(evt) {
            var elem = this
            elem.fieldContent = elem.innerHTML
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillMergetagsHTML(elem)
                },
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="2">
      <div id="col-field-html" class="col html form-field-col-ignored" data-col-id="1" data-autohide="">
        <div id="path-field-html-1-2-1" class="path-dynamic-field">
          <div id="form-progress-bar-container" style="
    display: flex;
    flex-direction: column;
    align-items: center;
    padding: 0 0 10px 0;
  ">
            <span id="form-progress-bar-text" style="color: #5a5a5a; font-size: 16px; padding: 0 0 8px 0">Giveaway in progress</span>
            <svg xmlns="http://www.w3.org/2000/svg" width="210px" height="7" viewBox="0 0 210 7" fill="none">
              <rect x="0.233337" y="0.11908" width="209" height="7" rx="3.19169" fill="#E4E4E4"></rect>
              <rect x="0.233337" y="0.11908" width="157.5" height="7" rx="3.19169" fill="#10B210"></rect>
            </svg>
          </div>
        </div>
        <script>
          document.querySelector('#path-field-html-1-2-1').addEventListener('path-dynamic-field-register', function(evt) {
            var elem = this
            elem.fieldContent = elem.innerHTML
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillMergetagsHTML(elem)
                },
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="3">
      <div id="col-field-html" class="col html form-field-col-ignored" data-col-id="1" data-autohide="">
        <div id="path-field-html-1-3-1" class="path-dynamic-field">
          <div style="text-align:center;font-size: 1.2em;
font-weight:bold;">Confirm below to continue</div>
        </div>
        <script>
          document.querySelector('#path-field-html-1-3-1').addEventListener('path-dynamic-field-register', function(evt) {
            var elem = this
            elem.fieldContent = elem.innerHTML
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillMergetagsHTML(elem)
                },
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="4">
      <div id="col-field-title" class="col title form-field-col" data-col-id="1" data-autohide="">
        <label class="label">Title</label>
        <select id="gender" data-type="title" name="gender" title="Title" class="path-form-field-with-feedback required path-dynamic-field">
          <option value=""> Select Title </option>
          <option value="M">Mr.</option>
          <option value="F">Ms.</option>
          <option value="F">Mrs.</option>
        </select>
        <span id="gender-title-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#gender[data-type=title]').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#gender-title-error-feedback')
            var elem = this
            evt.detail.assignToState('gender')
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  populate_options: renders.fillSelectOptions(elem, `
                    Select Title
              `),
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="5">
      <div id="col-field-first_name" class="col first-name form-field-col" data-col-id="1" data-autohide="">
        <label class="label">First Name</label>
        <input id="first_name" type="text" name="first_name" class="path-form-field-with-feedback path-dynamic-field required" title="First Name" value="">
        <span id="first_name-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#first_name').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#first_name-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('first_name')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
      <div id="col-field-last_name" class="col last-name form-field-col" data-col-id="2" data-autohide="">
        <label class="label">Last Name</label>
        <input id="last_name" type="text" name="last_name" class="path-form-field-with-feedback path-dynamic-field required" title="Last Name" value="">
        <span id="last_name-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#last_name').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#last_name-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('last_name')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="6">
      <div id="col-field-email" class="col e-mail form-field-col" data-col-id="1" data-autohide="">
        <label class="label">E-mail</label>
        <input id="email" list="email_domains" type="email" name="email" class="path-form-field-with-feedback path-dynamic-field required" title="Email" data-session-verification="-1" value="">
        <span id="emailmessage" class="invalid-feedback hidden path-form-feedback"></span>
        <datalist id="email_domains"></datalist>
        <script>
          document.querySelector('#email').addEventListener('path-dynamic-field-register', function(evt) {
            var domains = ["gmail.com", "yahoo.com", "hotmail.com", "aol.com", "hotmail.co.uk", "hotmail.fr", "msn.com", "yahoo.fr", "wanadoo.fr", "orange.fr", "comcast.net", "yahoo.co.uk", "yahoo.co.in", "live.com", "rediffmail.com", "free.fr",
              "gmx.de", "web.de", "yandex.ru", "ymail.com", "libero.it", "outlook.com", "uol.com", "bol.com", "mail.ru", "cox.net", "hotmail.it", "sbcglobal.net", "sfr.fr", "live.fr", "verizon.net", "live.co.uk", "googlemail.com", "yahoo.es",
              "ig.com", "live.nl", "bigpond.com", "terra.com", "yahoo.it", "neuf.fr", "yahoo.de", "alice.it", "rocketmail.com", "att.net", "laposte.net", "facebook.com", "bellsouth.net", "yahoo.in", "hotmail.es", "charter.net", "yahoo.ca",
              "yahoo.com.au", "rambler.ru", "hotmail.de", "tiscali.it", "shaw.ca", "yahoo.co.jp", "sky.com"
            ]
            var feedbackElem = document.querySelector('#emailmessage')
            var emailDomains = document.querySelector('#email_domains')
            var elem = this
            evt.detail.overrideOnChangeListener(function() {
              elem.addEventListener('input', evt.detail.listener(function(evt, setValue) {
                var value = evt.target.value
                setValue(value)
                var split = value.split('@')
                var username = split[0]
                var domain = split[1]
                var regex = domain && new RegExp('@' + domain)
                emailDomains.innerHTML = ''
                domains.forEach(function(domain) {
                  if (regex && regex.test('@' + domain) && username + '@' + domain !== value) {
                    var option = emailDomains.appendChild(document.createElement('option'))
                    option.setAttribute('value', username + '@' + domain)
                  }
                })
              }))
            })
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('test')
            evt.detail.assignToState('email', evt.detail.effects.test)
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="7">
      <div id="col-field-address1" class="col-8 address-1 form-field-col" data-col-id="1" data-autohide="">
        <label class="label">Street Address</label>
        <input id="addressform" type="text" name="addressform" title="Address" value="" class="path-dynamic-field path-form-field-with-feedback required" autocomplete="address-line1">
        <span id="address1-error-feedback" class="invalid-feedback hidden path-form-feedback invalid-postal"></span>
        <input id="address1" type="hidden" name="address1" title="Address" value="">
        <script>
          document.querySelector('#addressform').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#address1-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('address1')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
      <div id="col-field-address2" class="col address-2 form-field-col" data-col-id="2" data-autohide="">
        <label class="label">Suite</label>
        <input id="address2" type="text" name="address2" value="" class="path-form-field-with-feedback path-dynamic-field " autocomplete="address-line2">
        <span id="address2-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#address2').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#address2-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('address2')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="8">
      <div id="col-field-city" class="col city form-field-col" data-col-id="1" data-autohide="">
        <label class="label">City</label>
        <input id="city" type="text" name="city" title="City" value="" class="path-form-field-with-feedback path-dynamic-field required" autocomplete="address-level2">
        <span id="city-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#city').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#city-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('city')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="9">
      <div id="col-field-state" class="col-7 state form-field-col" data-col-id="1" data-autohide="">
        <label class="label">State</label>
        <select id="state" name="state" title="State" class="path-form-field-with-feedback path-dynamic-field required" value="" datavalue="">
          <option value=""> 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="DC">District Of Columbia</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">Louisiana</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>
        </select>
        <span id="state-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#state').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#state-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('state')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  populate_options: renders.fillSelectOptions(elem, `
                Select State
          `),
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
      <div id="col-field-zip" class="col zip-code form-field-col" data-col-id="2" data-autohide="">
        <label class="label">Zip Code</label>
        <input id="zip" type="text" name="zip" title="Zipcode" maxlength="5" data-session-verification="-1" value="" class="path-form-field-with-feedback required path-dynamic-field" pattern="[0-9]*" inputmode="numeric" autocomplete="postal-code">
        <span id="zip-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#zip').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#zip-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('zip')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillZip(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
            $(elem).change()
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="10">
      <div id="col-field-phone" class="col phone form-field-col" data-col-id="1" data-autohide="">
        <label class="label">Phone</label>
        <input id="phone" type="tel" name="phone" title="Phone" data-session-verification="-1" value="" class="path-dynamic-field path-form-field-with-feedback required" pattern="[0-9]*" inputmode="numeric" autocomplete="tel-national">
        <span id="phone-error-feedback" class="invalid-feedback hidden path-form-feedback invalid-phone"></span>
        <script>
          document.querySelector('#phone').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#phone-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.assignToState('phone')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInputPhone(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="11">
      <div id="col-field-dob" class="col date-of-birth form-field-col" data-col-id="1" data-autohide="">
        <label class="label">Date of Birth</label>
        <div class="row path-form-field-with-feedback-control">
          <div class="col">
            <select id="dob_month" name="dob_month" title="Dob Month" autocomplete="bday-month" class="path-dynamic-field required">
              <option value=""> Month </option>
              <option value="01">Jan</option>
              <option value="02">Feb</option>
              <option value="03">Mar</option>
              <option value="04">Apr</option>
              <option value="05">May</option>
              <option value="06">Jun</option>
              <option value="07">Jul</option>
              <option value="08">Aug</option>
              <option value="09">Sep</option>
              <option value="10">Oct</option>
              <option value="11">Nov</option>
              <option value="12">Dec</option>
            </select>
          </div>
          <div class="col">
            <select id="dob_day" name="dob_day" title="Dob Day" autocomplete="bday-day" class="path-dynamic-field required">
              <option value=""> Day </option>
              <option value="01">01</option>
              <option value="02">02</option>
              <option value="03">03</option>
              <option value="04">04</option>
              <option value="05">05</option>
              <option value="06">06</option>
              <option value="07">07</option>
              <option value="08">08</option>
              <option value="09">09</option>
              <option value="10">10</option>
              <option value="11">11</option>
              <option value="12">12</option>
              <option value="13">13</option>
              <option value="14">14</option>
              <option value="15">15</option>
              <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>
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              <option value="2000">2000</option>
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              <option value="1985">1985</option>
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              <option value="1983">1983</option>
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              <option value="1964">1964</option>
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              <option value="1944">1944</option>
              <option value="1943">1943</option>
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              <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>
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              <option value="1929">1929</option>
              <option value="1928">1928</option>
              <option value="1927">1927</option>
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Text Content

$100 TACO BELL


Value $100
MIN Entries 5,000
Nº Winners 1
EXP Date 07/31/2024
Contest Rules
04:46:54
Giveaway in progress
Confirm below to continue
Title Select Title Mr. Ms. Mrs.
First Name
Last Name
E-mail
Street Address
Suite
City
State Select State Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois
Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan
Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey
New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon
Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah
Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Phone
Date of Birth
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31
Year
20062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924

By checking the box, I consent to receive phone sales calls or SMS text messages
- Msg and data rates may apply - from Surveys2Cash, LegalFinderHQ, PLM on the
landline or mobile number I provided even if I am on the federal or state do not
call registry. I understand these calls and SMS text messages may be generated
using an autodialer and that consenting is not required to participate in the
offers promoted. I understand that I may revoke consent at any time. Text STOP
to opt out and HELP to receive help.
By checking the box, I agree that I am a US resident over the age of 18 and
agree to the Terms of Use and Privacy Policy, and site visit recordation by
TrustedForm and Jornaya, I agree to 3rd party marketing from GreenDot Bank and I
agree to receiving relevant ConsumerTestConnect emails.
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