wellmark.eesystem.hk Open in urlscan Pro
115.160.154.105  Public Scan

Form analysis
1 forms found in the DOM

POST /worker/register/register2

<form id="workerRegForm" action="/worker/register/register2" method="POST" enctype="multipart/form-data" novalidate="novalidate">
  <input class="form-control" type="hidden" id="FieldId_600_12" name="FieldId_600_12" value="WELLMARK">
  <input class="form-control" type="hidden" id="FieldId_1980" name="FieldId_1980" value="126896">
  <div class="row row_space">
    <div class="col-xs-12" id="title"> PERSONAL INFORMATION </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12 col-sm-4">
      <div class="input-required">
        <span class="required" aria-required="true">
          <span class="first-letter">First Name</span>
          <span class="second-letter">*</span>
        </span>
        <input class="form-control" type="text" id="FieldId_110" name="FieldId_110" value="" maxlength="40" size="20"><!-- Name -->
      </div>
    </div>
    <div class="col-xs-12 col-sm-4">
      <input class="form-control" type="text" id="FieldId_100" name="FieldId_100" placeholder="Last Name" value="" maxlength="40" size="20"><!-- Name -->
    </div>
    <div class="col-xs-12 col-sm-4">
      <input class="form-control" type="text" id="FieldId_120" name="FieldId_120" placeholder="Middle Name" value="" maxlength="40" size="20"><!-- Name -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-6">
      <div class="input-required">
        <span class="required" aria-required="true">
          <span class="first-letter">Date of Birth</span>
          <span class="second-letter">*</span>
        </span>
        <input class="form-control hasDatepicker" type="text" data-rule-dateformat="true" id="FieldId_180" name="FieldId_180" readonly="readonly" value="" size="10" onchange="workerReg.dob('en');">
      </div>
      <!-- Date of Birth -->
      <span id="FieldId_181TEXT"></span><input type="hidden" id="FieldId_181" name="FieldId_181" value="">
      <span id="FieldId_182TEXT"></span><input type="hidden" id="FieldId_182" name="FieldId_182" value="">
    </div>
    <div class="col-xs-6">
      <div class="select-required">
        <span>
          <span class="first-letter">Gender</span>
          <span class="second-letter">*</span>
        </span>
        <select class="form-control" id="FieldId_135" name="FieldId_135" style="color:#555;"><!-- Gender -->
          <option value=""></option>
          <option value="F">Female</option>
          <option value="M">Male</option>
        </select>
      </div>
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_190" name="FieldId_190" value="" placeholder="Place of Birth" maxlength="40" size="40"><!-- Place of Birth -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-6">
      <div class="select-required">
        <span>
          <span class="first-letter">Nationality</span>
          <span class="second-letter">*</span>
        </span>
        <select class="form-control" id="FieldId_220" name="FieldId_220" style="color:#999999;">
          <option value=""></option>
          <option value="INDONESIAN">Indonesian</option>
          <option value="FILIPINO">Filipino</option>
          <option value="THAI">Thai</option>
          <option value="NEPALESE">Nepalese</option>
          <option value="SRI LANKAN">Sri Lankan</option>
          <option value="BANGLADESHI">Bangladeshi</option>
          <option value="MADAGASCAN">Mafagascan</option>
          <option value="BURMESE">Burmese</option>
          <option value="INDIAN">Indian</option>
          <option value="KENYAN">Kenyan</option>
          <option value="MALAYSIAN">Malaysian</option>
          <option value="CAMBODIAN">Cambodian</option>
        </select><!-- Nationality -->
      </div>
    </div>
    <div class="col-xs-6">
      <input class="form-control hasDatepicker" type="text" data-rule-dateformat="true" id="FieldId_1100" name="FieldId_1100" value="" readonly="readonly" size="10" placeholder="Visa Expiry">
      <!-- Available Date -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-6">
      <div class="select-required">
        <span>
          <span class="first-letter">Religion</span>
          <span class="second-letter">*</span>
        </span>
        <select id="FieldId_210" name="FieldId_210" style="color:#999999;" class="form-control">
          <option selected="" value=""></option>
          <option value="Moslem">Moslem</option>
          <option value="Christian">Christian</option>
          <option value="Catholic">Catholic</option>
          <option value="Buddhist">Buddhist</option>
          <option value="Hindus">Hindus</option>
          <option value="Islam">Islam</option>
          <option value="Others">Others</option>
        </select>
      </div>
    </div>
    <div class="col-xs-6">
      <input class="form-control hasDatepicker" type="text" data-rule-dateformat="true" id="FieldId_1101" name="FieldId_1101" readonly="readonly" value="" size="10" placeholder="Available Date">
      <!-- Available Date -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-6">
      <div class="select-required">
        <span>
          <span class="first-letter">Marital Status</span>
          <span class="second-letter">*</span>
        </span>
        <select class="form-control" id="FieldId_200" name="FieldId_200"><!-- Marital Status -->
          <option value=""></option>
          <option value="SINGLE">Single</option>
          <option value="MARRIED">Married</option>
          <option value="SEPARATE">Separated</option>
          <option value="DIVORCED">Divorced</option>
          <option value="WIDOWED">Widowed</option>
          <option value="SOLO">Solo</option>
        </select>
      </div>
    </div>
    <div class="col-xs-6">
      <div class="select-required">
        <span>
          <span class="first-letter">Education</span>
          <span class="second-letter">*</span>
        </span>
        <select class="form-control" id="FieldId_270" name="FieldId_270"><!-- Education -->
          <option value=""></option>
          <option value="BELOW ELEMENTARY">Below Elementary</option>
          <option value="ELEMENTARY">Elementary</option>
          <option value="JUNIOR HIGH">Junior High</option>
          <option value="SENIOR HIGH">Senior High</option>
          <option value="COLLEGE">College</option>
          <option value="UNIVERSITY">University</option>
        </select>
      </div>
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-4">
      <div class="input-required">
        <span class="required" aria-required="true">
          <span class="first-letter">Height</span>
          <span class="second-letter">*</span>
        </span>
        <input class="form-control" type="text" id="FieldId_230" name="FieldId_230" value="" maxlength="8" size="8"><!-- Height -->
      </div>
    </div>
    <div class="col-xs-2" style="padding-top:10px !important;"> cm<!-- Height Unit -->
    </div>
    <div class="col-xs-4">
      <div class="input-required">
        <span class="required" aria-required="true">
          <span class="first-letter">Weight</span>
          <span class="second-letter">*</span>
        </span>
        <input class="form-control" type="text" id="FieldId_240" name="FieldId_240" value="" maxlength="8" size="8"><!-- Height -->
      </div>
    </div>
    <div class="col-xs-2" style="padding-top:10px !important;"> kg<!-- Weight Unit -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_140" name="FieldId_140" value="" placeholder="Address 1" maxlength="50" size="50"><!-- Address 1 -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_141" name="FieldId_141" value="" placeholder="Address 2" maxlength="50" size="50"><!-- Address 2 -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12" id="title"> CONTACT INFORMATION </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <div class="input-required">
        <span class="required" aria-required="true">
          <span class="first-letter">Mobile 1</span>
          <span class="second-letter">*</span>
        </span>
        <input class="form-control" type="text" id="FieldId_167" name="FieldId_167" value="" maxlength="20" size="20"><!-- Mobile 1-->
      </div>
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_150" name="FieldId_150" value="" placeholder="Mobile 2" maxlength="20" size="20"><!-- Mobile 2-->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_165" name="FieldId_165" value="" placeholder="Email" maxlength="20" size="20"><!-- Email -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_609_11_2" name="FieldId_609_11_2" value="" placeholder="Facebook" maxlength="20" size="20"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_271" name="FieldId_271" value="" placeholder="Emergency Contact Person 1" maxlength="30" size="30"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_272" name="FieldId_272" value="" placeholder="Emergency Relationship 1" maxlength="20" size="20"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_274" name="FieldId_274" value="" placeholder="Emergency Tel 1" maxlength="20" size="20"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_273" name="FieldId_273" value="" placeholder="Emergency Address 1" maxlength="100" size="100"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_275" name="FieldId_275" value="" placeholder="Emergency Contact Person 2" maxlength="30" size="30"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_276" name="FieldId_276" value="" placeholder="Emergency Relationship 2" maxlength="20" size="20"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_278" name="FieldId_278" value="" placeholder="Emergency Tel 2" maxlength="20" size="20"><!-- Facebook -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_277" name="FieldId_277" value="" placeholder="Emergency Address 2" maxlength="100" size="100"><!-- Facebook -->
    </div>
  </div>
  <!-- Facebook -->
  <div class="row row_space">
    <div class="col-xs-12" id="title"> PASSPORT INFORMATION </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_250" name="FieldId_250" value="" placeholder="Passport No." maxlength="20" size="20"><!-- Passport No. -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-6">
      <input class="form-control hasDatepicker" type="text" data-rule-dateformat="true" id="FieldId_252" name="FieldId_252" readonly="readonly" value="" size="10" placeholder="Date of Issue"><!-- Issue Date -->
    </div>
    <div class="col-xs-6">
      <input class="form-control hasDatepicker" type="text" data-rule-dateformat="true" id="FieldId_251" name="FieldId_251" readonly="readonly" value="" size="10" placeholder="Date of Expiry"><!-- Expiry Date -->
    </div>
  </div>
  <div class="row row_space">
    <div class="col-xs-12">
      <input class="form-control" type="text" id="FieldId_253" name="FieldId_253" value="" placeholder="Place of Issue" maxlength="20" size="20"><!-- Place of Issue -->
    </div>
  </div>
  <div class="row btn_space">
    <div class="col-md-12 form-field" id="next" onclick="workerReg.toPage2();">
      <div id="red_button" style="float: right;">NEXT</div>
    </div>
  </div>
</form>

Text Content

1

2

3

4

PERSONAL INFORMATION
First Name *


Date of Birth *
Gender * Female Male

Nationality * Indonesian Filipino Thai Nepalese Sri Lankan Bangladeshi
Mafagascan Burmese Indian Kenyan Malaysian Cambodian

Religion * Moslem Christian Catholic Buddhist Hindus Islam Others

Marital Status * Single Married Separated Divorced Widowed Solo
Education * Below Elementary Elementary Junior High Senior High College
University
Height *
cm
Weight *
kg


CONTACT INFORMATION
Mobile 1 *











PASSPORT INFORMATION



NEXT


License No.: 62330