ophtecs.swisslens.ch Open in urlscan Pro
195.15.232.39  Public Scan

Form analysis
1 forms found in the DOM

POST https://ophtecs.swisslens.ch/de_DE

<form action="https://ophtecs.swisslens.ch/de_DE" method="POST" accept-charset="UTF-8">
  <input type="hidden" name="_token" value="8vZNcpwQeVSTuw2s7fUAWQCT0UQnZBwBo3MPGzbc">
  <div class="grid grid-cols-12 gap-2 mb-10">
    <!-- ----------------------------------------------------------- -->
    <!-- section title : company -->
    <div class="col-span-4 line-through"></div>
    <div class="col-span-4">
      <div class="text-center text-primary-500">Firma</div>
    </div>
    <div class="col-span-4 line-through"></div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : entity type -->
    <div class="field-wrapper col-span-12 ">
      <label class="cs-form__label" for="entity_type">Art *</label>
      <select id="entity_type" type="text" class="cs-form__select w-full" name="entity_type">
        <option value="">bitte auswählen...</option>
        <option value="STORE" selected="">Augenoptik-/Kontaktlinsenfachgeschäft</option>
        <option value="RESELLER">Vertrieb</option>
        <option value="OPTOMETRIST">Optiker/Optometrist</option>
        <option value="OPHTHALMOLOGIST">Augenarzt</option>
        <option value="HOSPITAL">Krankenhaus/Klinik</option>
        <option value="SCHOOL">Schule/Universität</option>
        <option value="OTHER">andere</option>
      </select>
    </div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : company name -->
    <div class="field-wrapper col-span-12 ">
      <label class="cs-form__label" for="company_name">Firma *</label>
      <input id="company_name" type="text" class="cs-form__input w-full" name="company_name" value="">
    </div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : company name complement -->
    <div class="field-wrapper col-span-12 ">
      <label class="cs-form__label" for="company_name_complement">Firmazusatz</label>
      <input id="company_name_complement" type="text" class="cs-form__input w-full" name="company_name_complement" value="">
    </div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : VAT -->
    <div class="field-wrapper col-span-7 ">
      <label class="cs-form__label" for="vat">USt-IdNr</label>
      <input id="vat" type="text" class="cs-form__input w-full" name="vat" value="">
    </div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : Group memeber number => Ophtecs client number -->
    <div class="field-wrapper md:col-span-8 col-span-12 ">
      <label class="cs-form__label" for="group_member_number">Ophtecs client number</label>
      <input id="group_member_number" type="text" class="cs-form__input w-full" name="group_member_number" value="">
    </div>
    <div class="md:col-span-4 md:block hidden"></div>
    <!-- ----------------------------------------------------------- -->
    <!-- ----------------------------------------------------------- -->
    <!-- section title : delivery address -->
    <div class="col-span-4 line-through"></div>
    <div class="col-span-4">
      <div class="text-center text-primary-500">Kundenadresse</div>
    </div>
    <div class="col-span-4 line-through"></div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : address line 1 -->
    <div class="field-wrapper col-span-12 ">
      <label class="cs-form__label" for="del_address_line1">Adresszeile 1 (Firmennamen nicht wiederholen) *</label>
      <input id="del_address_line1" type="text" class="cs-form__input w-full" name="del_address_line1" value="">
    </div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : address line 2 -->
    <div class="field-wrapper col-span-12 ">
      <label class="cs-form__label" for="del_address_line2">Adresszeile 2</label>
      <input id="del_address_line2" type="text" class="cs-form__input w-full" name="del_address_line2" value="">
    </div>
    <!-- ----------------------------------------------------------- -->
    <!-- FORM : postcode -->
    <div class="field-wrapper col-span-4 ">
      <label class="cs-form__label" for="del_address_postcode">PLZ (nur Zahlen) *</label>
      <input id="del_address_postcode" type="text" class="cs-form__input w-full" name="del_address_postcode" value="">
    </div>
    <!-- FORM : city -->
    <div class="field-wrapper col-span-8 ">
      <label class="cs-form__label" for="del_address_city">Ort *</label>
      <input id="del_address_city" type="text" class="cs-form__input w-full" name="del_address_city" value="">
    </div>
    <!-- ----------------------------------------------------------- -->
    <!-- send button -->
    <div class="field-wrapper col-span-12">
      <button type="submit" class="cs-btn cs-btn--primary text-center text-lg w-full">Anmeldung</button>
    </div>
  </div>
</form>

Text Content

Firma

Art * bitte auswählen... Augenoptik-/Kontaktlinsenfachgeschäft Vertrieb
Optiker/Optometrist Augenarzt Krankenhaus/Klinik Schule/Universität andere
Firma *
Firmazusatz
USt-IdNr
Ophtecs client number


Kundenadresse

Adresszeile 1 (Firmennamen nicht wiederholen) *
Adresszeile 2
PLZ (nur Zahlen) *
Ort *
Anmeldung