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colliercounty.alastar.com Open in urlscan Pro
147.120.11.175  Public Scan

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URL: https://colliercounty.alastar.com/
Submission: On January 02 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

POST /forms/911helpmecolliercounty/

<form id="helpForm" class="form-horizontal" method="POST" enctype="multipart/form-data" style="margin: 0;" action="/forms/911helpmecolliercounty/" encoding="multipart/form-data">
  <input type="hidden" name="csrfToken" value="7242aca05d1fa772aff3f948edd50bd3a8aabb9e-1704215458620-81ae99cfafff5fa6648dac60">
  <input id="forceRedirect" name="forceRedirect" type="hidden">
  <input id="headerSiteId" name="headerSiteId" type="hidden" value="">
  <div class="panel" style="border-color: #dd0000;">
    <div class="panel-heading display-flex" style="background-color: #dd0000; color: #ffffff; border-color: #dd0000;">
      <div class="flex-grow display-flex flex-center-vertical">
        <h4 class="panel-title">
          <a data-toggle="collapse" href="#locationBody">
                            Where is your emergency located?
                        </a>
        </h4>
      </div>
    </div>
    <div class="panel-body panel-collape collapse in" id="locationBody">
      <div class="form-group">
        <label for="streetAddress" class="col-md-4 control-label" id="streetAddress_label">Street Address</label>
        <div class="col-md-8">
          <span tabindex="-1" class="k-autocomplete k-input form-control k-autocomplete-clearable k-input-solid k-input-md k-rounded-md" style=""><input id="streetAddress" name="streetAddress" type="text" class="form-control k-input-inner"
              autocomplete="off" value="" data-role="autocomplete" role="combobox" aria-expanded="false" aria-disabled="false" aria-readonly="false" aria-autocomplete="list" aria-controls="streetAddress_listbox"><span unselectable="on"
              class="k-clear-value k-hidden" title="clear" role="button" tabindex="-1"><span class="k-icon k-i-x"></span></span><span class="k-icon k-i-loading k-input-loading-icon k-hidden"></span></span>
        </div>
      </div>
      <div class="form-group">
        <label for="apartmentNumber" class="col-md-4 control-label">Apartment Number</label>
        <div class="col-md-8">
          <input id="apartmentNumber" name="apartmentNumber" type="text" class="form-control" autocomplete="off" value="">
        </div>
      </div>
      <div class="form-group">
        <label for="city" class="col-md-4 control-label">City</label>
        <div class="col-md-8">
          <input id="city" name="city" type="text" class="form-control" value="" autocomplete="off">
        </div>
      </div>
      <div class="form-group">
        <label for="state" class="col-md-4 control-label">State/Territory</label>
        <div class="col-md-8">
          <input id="state" name="state" type="text" class="form-control" value="" autocomplete="off">
        </div>
      </div>
    </div>
  </div>
  <div class="panel" style="border-color: #dd0000;">
    <div class="panel-heading display-flex" style="background-color: #dd0000; color: #ffffff; border-color: #dd0000;">
      <div class="flex-grow display-flex flex-center-vertical">
        <h4 class="panel-title">
          <a data-toggle="collapse" href="#emergencyBody">
                            What is your emergency?
                        </a>
        </h4>
      </div>
    </div>
    <div id="emergencyBody" class="panel-body panel-collape collapse in">
      <div class="form-group">
        <label for="remarks" class="col-md-4 control-label">Remarks</label>
        <div class="col-md-8">
          <textarea id="remarks" name="remarks" type="text" class="form-control" rows="5"></textarea>
        </div>
      </div>
      <div class="form-group">
        <label for="contactPermission" class="col-md-4 control-label" id="contactPermission_label">If we need more information, may we contact you?</label>
        <div class="col-md-8">
          <span class="k-switch k-switch-md k-rounded-full k-switch-off" role="switch" tabindex="0" aria-checked="false" aria-labelledby="contactPermission_label" style=""><input id="contactPermission" name="contactPermission" type="checkbox"
              class="k-switch" data-role="switch" style="display: none;"><span class="k-switch-track k-rounded-full"><span class="k-switch-label-on" aria-hidden="true">Yes</span><span class="k-switch-label-off">No</span></span><span
              class="k-switch-thumb-wrap"><span class="k-switch-thumb k-rounded-full"></span></span></span>
        </div>
      </div>
      <div class="form-group">
        <label class="col-md-4 control-label">Attachments (photos only)</label>
        <div class="col-md-8">
          <input id="attachmentSuffix" type="hidden" value="">
          <input id="maxNumAttachments" type="hidden" value="4">
          <div id="attachmentValidation" style="display: none;">
            <h3>
              <span class="label label-danger">VALIDATION FAILURE: A maximum of 1 attachments are supported.</span>
            </h3>
          </div>
          <div>
            <input id="hashChanges" name="hashChanges" type="hidden">
            <input id="allImages" name="allImages" type="hidden" value="true">
            <input id="isIcsAttachments" name="isIcsAttachments" type="hidden" value="false">
            <input id="attachmentId-1" name="attachmentId-1" type="hidden" value="">
            <input id="attachmentName-1" name="attachmentName-1" type="hidden" value="">
            <input id="attachmentDeleted-1" name="attachmentDeleted-1" type="hidden" value="false">
            <div class="k-widget k-upload k-upload-sync k-upload-empty">
              <div class="k-dropzone">
                <div class="k-button k-button-md k-rounded-md k-button-solid k-button-solid-base k-upload-button"><input type="file" accept="image/*" class="form-control" id="attachments" name="attachments" data-message="" data-extensions=""
                    multiple="multiple" data-role="upload" aria-label="Select images..." autocomplete="off"><span>Select images...</span></div>
              </div>
            </div>
          </div>
          <table id="attachmentsTable" class="table table-bordered table-condensed">
            <tbody>
              <tr id="attachmentRow-1" class="attachmentRow" data-id="" data-sequence="1" style="display: none;">
                <td style="vertical-align: middle;">
                  <i class="fa fa-file-alt" style="font-size: 20px; vertical-align: middle;"></i>
                </td>
                <td style="width: 125px;" class="ics-time-content">
                </td>
                <td style="width: 100px;">
                </td>
                <td class="rotateAttachmentCell" style="width: 60px; display: none;">
                  <button id="rotateAttachment-1" type="button" class="btn btn-default"> Rotate </button>
                  <input id="rotateValue-1" name="rotateValue-1" type="hidden" value="0">
                </td>
                <td style="width: 60px;">
                  <button id="deleteAttachment-1" type="button" class="btn btn-danger"> Delete </button>
                </td>
              </tr>
            </tbody>
          </table>
        </div>
      </div>
    </div>
  </div>
  <div class="panel" style="border-color: #dd0000;">
    <div class="panel-heading display-flex" style="background-color: #dd0000; color: #ffffff; border-color: #dd0000;">
      <div class="flex-grow display-flex flex-center-vertical">
        <h4 class="panel-title">
          <a data-toggle="collapse" href="#contactBody">
                            How can we contact you?
                        </a>
        </h4>
      </div>
    </div>
    <div id="contactBody" class="panel-body panel-collape collapse in">
      <div class="form-group">
        <label for="contactFirstName" class="col-md-4 control-label">First Name</label>
        <div class="col-md-8">
          <input id="contactFirstName" name="contactFirstName" type="text" class="form-control" value="">
        </div>
      </div>
      <div class="form-group">
        <label for="contactLastName" class="col-md-4 control-label">Last Name</label>
        <div class="col-md-8">
          <input id="contactLastName" name="contactLastName" type="text" class="form-control" value="">
        </div>
      </div>
      <div class="form-group">
        <label for="contactPhone" class="col-md-4 control-label">Phone</label>
        <div class="col-md-8">
          <input id="contactPhone" name="contactPhone" type="text" class="form-control" value="">
        </div>
      </div>
      <div class="form-group">
        <label for="contactEmail" class="col-md-4 control-label">Email</label>
        <div class="col-md-8">
          <input id="contactEmail" name="contactEmail" type="text" class="form-control" value="">
        </div>
      </div>
      <div class="form-group">
        <div class="col-md-8 col-md-offset-4">
          <div class="g-recaptcha" data-sitekey="6LcXGjYUAAAAAL7KTEaWxrGauqgb6ZsIeFQcXN0d">
            <div style="width: 304px; height: 78px;">
              <div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-hv3tv8xc0fz" frameborder="0" scrolling="no"
                  sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
                  src="https://www.google.com/recaptcha/api2/anchor?ar=1&amp;k=6LcXGjYUAAAAAL7KTEaWxrGauqgb6ZsIeFQcXN0d&amp;co=aHR0cHM6Ly9jb2xsaWVyY291bnR5LmFsYXN0YXIuY29tOjQ0Mw..&amp;hl=en&amp;v=u-xcq3POCWFlCr3x8_IPxgPu&amp;size=normal&amp;cb=dmje4oipoo4v"></iframe>
              </div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
                style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
            </div><iframe style="display: none;"></iframe>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="type-required">
    <button id="saveAndClose" type="button" class="btn btn-primary"> Save and Submit </button>
  </div>
</form>

Text Content

911HelpMe Request Form Collier County
911Helpme Request Form

WHERE IS YOUR EMERGENCY LOCATED?

Street Address

Apartment Number

City

State/Territory


WHAT IS YOUR EMERGENCY?

Remarks

If we need more information, may we contact you?
YesNo
Attachments (photos only)


VALIDATION FAILURE: A MAXIMUM OF 1 ATTACHMENTS ARE SUPPORTED.

Select images...

Rotate Delete

HOW CAN WE CONTACT YOU?

First Name

Last Name

Phone

Email


Save and Submit
Cancel Send

×

LOCATION

Unable to automatically determine your location. You will need to manually enter
your address. Error: 1 - User denied Geolocation
OK