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jaijawan.vedikaopticals.com Open in urlscan Pro
2a02:4780:b:662:0:953:1edb:4  Public Scan

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URL: https://jaijawan.vedikaopticals.com/
Submission: On January 25 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

POST https://jaijawan.vedikaopticals.com/agniveer

<form action="https://jaijawan.vedikaopticals.com/agniveer" enctype="multipart/form-data" method="POST">
  <input type="hidden" name="_token" value="drD7CgbSFGvGQQKTpYfNE502NOPrmf56nIPVlNzS"> <input type="hidden" value="Against Agniveer" name="form_status" required="">
  <div class="row align-items-center my-lg-5">
    <div class="col-lg-1 text-lg-end">
      <label for="" class="h5 d-lg-flex justify-content-end">Name <span class="text-danger">*</span></label>
    </div>
    <div class="col-lg-3 my-lg-0 mb-3">
      <input name="name" required="" placeholder="" class="input-field" type="text">
    </div>
    <div class="col-lg-3 text-lg-end">
      <label for="" class="h5 d-lg-flex justify-content-end">Contact Number <span class="text-danger">*</span></label>
    </div>
    <div class="col-lg-5 my-lg-0 mb-3">
      <input name="contact_no" required="" placeholder="" class="input-field" type="text">
    </div>
  </div>
  <div class="row align-items-center my-lg-5">
    <div class="col-lg-1 text-lg-end">
      <label for="" class="h5 d-lg-flex">Gender <span class="text-danger">*</span></label>
    </div>
    <div class="col-lg-3 my-lg-0 mb-3">
      <div class="select">
        <select id="format" name="gender" required="">
          <option selected="" disabled="" value="">Choose Option</option>
          <option value="pdf">Male</option>
          <option value="txt">Female</option>
          <option value="epub">Other</option>
        </select>
      </div>
    </div>
    <div class="col-lg-1"></div>
    <div class="col-lg-1 text-lg-end">
      <label for="" class="h5 d-lg-flex justify-content-end">State <span class="text-danger">*</span></label>
    </div>
    <div class="col-lg-3 my-lg-0 mb-3">
      <div class="select">
        <select id="state" name="state" required="">
          <option selected="" disabled="" value="">Choose Option</option>
          <option value="1">ANDAMAN AND NICOBAR ISLANDS</option>
          <option value="2">ANDHRA PRADESH</option>
          <option value="3">ARUNACHAL PRADESH</option>
          <option value="4">ASSAM</option>
          <option value="5">BIHAR</option>
          <option value="6">CHANDIGARH</option>
          <option value="7">CHHATTISGARH</option>
          <option value="8">DADRA AND NAGAR HAVELI</option>
          <option value="9">DAMAN AND DIU</option>
          <option value="10">DELHI</option>
          <option value="11">GOA</option>
          <option value="12">GUJARAT</option>
          <option value="13">HARYANA</option>
          <option value="14">HIMACHAL PRADESH</option>
          <option value="15">JAMMU AND KASHMIR</option>
          <option value="16">JKARKHAND</option>
          <option value="17">KARNATAKA</option>
          <option value="18">KERALA</option>
          <option value="19">LADAKH</option>
          <option value="20">LAKSHADWEEP</option>
          <option value="21">MADHYA PRADESH</option>
          <option value="22">MAHARASHTRA</option>
          <option value="23">MANIPUR</option>
          <option value="24">MEGHALAYA</option>
          <option value="25">MIZORAM</option>
          <option value="26">NAGALAND</option>
          <option value="27">ODISHA</option>
          <option value="28">PUDUCHERRY</option>
          <option value="29">PUNJAB</option>
          <option value="30">RAJASTHAN</option>
          <option value="31">SIKKIM</option>
          <option value="32">TAMIL NADU</option>
          <option value="33">TELANGANA</option>
          <option value="34">TRIPURA</option>
          <option value="35">UTTAR KHAND</option>
          <option value="36">UTTAR PRADESH</option>
          <option value="37">WEST BENGAL</option>
        </select>
      </div>
    </div>
  </div>
  <div class="row align-items-center my-lg-5">
    <div class="col-lg-1 text-lg-end">
      <label for="" class="h5 d-lg-flex">District <span class="text-danger">*</span></label>
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    <div class="col-lg-3 my-lg-0 mb-3">
      <div class="select my-lg-0 mb-3">
        <select id="district" name="district" required="">
          <option selected="" disabled="" value="">Choose Option</option>
        </select>
      </div>
    </div>
    <div class="col-lg-1"></div>
    <div class="col-lg-1 text-lg-end">
      <label for="" class="h5 d-lg-flex justify-content-end">Block <span class="text-danger">*</span></label>
    </div>
    <div class="col-lg-3 my-lg-0 mb-3">
      <div class="select">
        <select id="blocks" name="block" required="">
          <option selected="" disabled="" value="">Choose Option</option>
        </select>
      </div>
    </div>
  </div>
  <div class="row align-items-center my-lg-5">
    <div class="col-lg-2">
      <label for="" class="h5">whatsapp No. <span class="text-danger">*</span></label>
    </div>
    <div class="col-lg-3 my-lg-0 mb-3">
      <input placeholder="" class="input-field" type="text" name="whatsapp_no" required="">
    </div>
    <div class="col-lg-6 d-lg-flex">
      <div class="d-lg-flex">
        <label for="" class="h5 d-lg-flex">Upload Document <span class="text-danger">*</span></label>
      </div>
      <input id="upload" type="file" class="mx-3 my-3" accept="image/*" name="document" required="">
    </div>
  </div>
  <div class="form-check">
    <input class="form-check-input" type="checkbox" value="" id="flexCheckDefault">
    <label class="form-check-label" for="flexCheckDefault">Lorem ipsum dolor sit amet consectetur adipisicing elit. Natus, quo!</label>
  </div>
  <div class="form-button mt-3">
    <button type="submit" class="btn btn-lg btn-info h2 text-light text-capitalize px-5">submit <i class="fa-solid fa-arrow-right-long"></i></button>
  </div>
</form>

Text Content

JAI JAWAN
 * NYAY
 * KA HAQ
 * MILNE
 * TAK




AGAINST AGNIVEER

Thank you for choosing to be a Nyay Yoddha, your participation will help realise
the dream of an India that is just and progressive.

* Marked Fields Are Compulsory

Name *

Contact Number *

Gender *
Choose Option Male Female Other

State *
Choose Option ANDAMAN AND NICOBAR ISLANDS ANDHRA PRADESH ARUNACHAL PRADESH ASSAM
BIHAR CHANDIGARH CHHATTISGARH DADRA AND NAGAR HAVELI DAMAN AND DIU DELHI GOA
GUJARAT HARYANA HIMACHAL PRADESH JAMMU AND KASHMIR JKARKHAND KARNATAKA KERALA
LADAKH LAKSHADWEEP MADHYA PRADESH MAHARASHTRA MANIPUR MEGHALAYA MIZORAM NAGALAND
ODISHA PUDUCHERRY PUNJAB RAJASTHAN SIKKIM TAMIL NADU TELANGANA TRIPURA UTTAR
KHAND UTTAR PRADESH WEST BENGAL
District *
Choose Option

Block *
Choose Option
whatsapp No. *

Upload Document *
Lorem ipsum dolor sit amet consectetur adipisicing elit. Natus, quo!
submit

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