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screenage2021.virtex.in Open in urlscan Pro
65.1.222.118  Public Scan

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URL: https://screenage2021.virtex.in/registration/
Submission: On October 21 via api from SG — Scanned from DE

Form analysis 1 forms found in the DOM

<form class="" id="RegForm">
  <div class="row">
    <div class="col-lg-6 col-md-6 col-sm-12 mt-3">
      <div class="form-group">
        <label class="text-left">Initials<span class="mandatory">* </span></label>
        <select class="form-control" name="initials" id="initials">
          <option selected="selected" value="Mr.">Mr.</option>
          <option value="Mrs.">Mrs.</option>
          <option value="Miss.">Miss.</option>
        </select>
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 mt-3">
      <div class="form-group">
        <label class="text-left">Full Name<span class="mandatory">* </span></label>
        <input class="form-control" type="text" name="first_name" id="first_name" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 mt-3">
      <div class="form-group">
        <label class="text-left">Designation<span class="mandatory">* </span></label>
        <input class="form-control" type="text" name="Job" id="Job" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 mt-3">
      <div class="form-group">
        <label class="text-left"> Organization Name <span class="mandatory">* </span></label>
        <input class="form-control" type="text" name="Organization" id="Organization" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 mt-3">
      <div class="form-group">
        <label class="text-left"> Contact No. <span class="mandatory">* </span></label>
        <input class="form-control" type="number" oninput="javascript: if (this.value.length > this.maxLength) this.value = this.value.slice(0, this.maxLength);" name="mobile" id="mobile" maxlength="10" pattern="\d{10}" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 mt-3">
      <div class="form-group">
        <label class="text-left">Official Email Id<span class="mandatory">* </span></label>
        <input class="form-control" type="email" name="email" id="email" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 mt-3">
      <div class="form-group">
        <label class="text-left"> City <span class="mandatory">* </span></label>
        <input class="form-control" type="text" name="city" id="city" required="">
      </div>
    </div>
    <div class="col-xs-12 col-sm-12 col-md-12 mt-2">
      <div class="form-group">
        <div class="row ml-0">
          <div class="form-check col-md-12">
            <input class="form-check-input" type="checkbox" checked="" name="attend" id="exampleRadios1" value="Awards" disabled="">
            <label class="form-check-label" for="exampleRadios1" style="font-weight: 300; font-size: 14px;"> By supplying my contact information, I authorize the organiser exchange4media and sponsors to contact me via personalized communications
              about their products and services via email and phone. See our <a href="https://www.exchange4media.com/privacy-policy.html" target="-blank">Privacy Policy</a> for more details or to opt-out at any time.<span class="mandatory">* </span>
            </label>
          </div>
        </div>
      </div>
    </div>
    <div class="text-center col-lg-12 col-md-12 col-sm-12 mt-3">
      <div class="form-group">
        <button class="btn login-btn" type="submit" name="" id="register-btn1"> Submit </button>
      </div>
    </div>
  </div>
</form>

Text Content

REGISTRATION

Initials* Mr. Mrs. Miss.
Full Name*
Designation*
Organization Name *
Contact No. *
Official Email Id*
City *
By supplying my contact information, I authorize the organiser exchange4media
and sponsors to contact me via personalized communications about their products
and services via email and phone. See our Privacy Policy for more details or to
opt-out at any time.*
Submit