veolia.payboost.com Open in urlscan Pro
15.236.44.100  Public Scan

Form analysis
1 forms found in the DOM

Name: acces_form — POST /TOP/veolia/?op=073606001524210222320&mt=6473

<form name="acces_form" id="acces_form" method="post" action="/TOP/veolia/?op=073606001524210222320&amp;mt=6473" role="form">
  <input type="hidden" name="acces_form_valid" value="e4CS3sX5qOQEe1PLsW6CVc0gUEFfxZ69BWhUNNyoDOA">
  <div class="row">
    <div class="col-md-6 col-md-push-3 col-sm-8 col-sm-push-2 col-xs-12">
      <p class="intro">Veuillez saisir la référence et le montant de votre facture :</p>
    </div>
  </div>
  <div class="row ">
    <div class="col-md-6 col-md-push-3 col-sm-8 col-sm-push-2 col-xs-12">
      <label for="bill_reference">Référence de votre facture</label>
      <div class="input-wrapper input-bill">
        <span class="top-icon-ref_facture icon-left"></span>
        <input type="tel" id="bill_reference" name="bill_reference" value="073606001524210222320" pattern="([0-9]*)" input_pattern="^([0-9]*)$" onchange="this.value=this.value.trim()" tabindex="1" autocomplete="off">
        <a href="javascript:void(0)" class="top-icon-infos icon-right help-bill-externalid"></a>
      </div>
    </div>
  </div>
  <div class="row ">
    <div class="col-md-6 col-md-push-3 col-sm-8 col-sm-push-2 col-xs-12">
      <label for="bill_amount">Montant à payer</label>
      <div class="input-wrapper input-amount">
        <span class="top-icon-montant icon-left"></span>
        <input type="text" id="bill_amount" name="bill_amount" value="64,73" pattern="^(?:(?=.{1,9}$)\d{1,6}(?:[,|.]{1,1}\d{1,2})+|(?=.{1,6}$)\d+)$" input_pattern="^[0-9]+[\.|\,]{0,1}[0-9]{0,2}?$" maxlength="9" tabindex="2" autocomplete="off">
        <a href="javascript:void(0)" class="top-icon-infos icon-right help-bill-amount"></a>
      </div>
    </div>
  </div>
  <div class="row ">
    <div class="col-md-6 col-md-push-3 col-sm-8 col-sm-push-2 col-xs-12 highlight">
      <label for="email">Votre adresse e-mail</label>
      <div class="input-wrapper input-email">
        <span class="top-icon-email icon-left"></span>
        <input type="email" id="email" name="email" value="" tabindex="3">
      </div>
      <p class="note">Votre adresse e-mail permet de recevoir votre confirmation de paiement</p>
    </div>
  </div>
  <div class="btns">
    <button class="btn btn-primary btn-valid-information" type="submit" tabindex="5"> Valider les informations <span class="top-icon-fleche_droite"></span>
    </button>
  </div>
</form>

Text Content

PAYER MA FACTURE

Les informations saisies sont incorrectes

Veuillez saisir la référence et le montant de votre facture :

Référence de votre facture

Montant à payer

Votre adresse e-mail


Votre adresse e-mail permet de recevoir votre confirmation de paiement

Valider les informations
Mentions légales