www.prmpwa.sndigitalhub.com
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135.181.133.251
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URL:
https://www.prmpwa.sndigitalhub.com/
Submission: On May 02 via api from US — Scanned from FI
Submission: On May 02 via api from US — Scanned from FI
Form analysis 3 forms found in the DOM
<form action="" class="p-5 bg-white" data-id="VzVaNFU9DDo" align="left" onsubmit="DataFormSubmit (event,this)">
<div class="row form-group">
<div class="col-md-4 mb-3 mb-md-0"><label id="label_1">Name <font color="red"><i class="fa fa-star fa-1"></i></font></label> <input type="text" class="form-control" name="field_1" placeholder="Enter Here" required=""></div>
<div class="col-md-4 mb-3 mb-md-0"><label id="label_11">Address <font color="red"><i class="fa fa-star fa-1"></i></font></label> <input type="text" class="form-control" name="field_11" placeholder="Enter Here" required=""></div>
<div class="col-md-4 mb-3 mb-md-0"><label id="label_3">City <font color="red"><i class="fa fa-star fa-1"></i></font></label> <input type="text" class="form-control" name="field_3" placeholder="Enter Here" required=""></div>
</div>
<div class="row form-group">
<div class="col-md-4 mb-3 mb-md-0"><label id="label_4">State <font color="red"><i class="fa fa-star fa-1"></i></font></label> <input type="text" class="form-control" name="field_4" placeholder="Enter Here" required=""></div>
<div class="col-md-4 mb-3 mb-md-0"><label id="label_5">Pincode <font color="red"><i class="fa fa-star fa-1"></i></font></label> <input type="number" class="form-control" name="field_5" placeholder="Enter Here" required=""></div>
<div class="col-md-4 mb-3 mb-md-0"><label id="label_12">Contact no. <font color="red"><i class="fa fa-star fa-1"></i></font></label> <input type="number" class="form-control" name="field_12" placeholder="Enter Here" required=""></div>
</div>
<div class="row form-group">
<div class="col-md-4 mb-3 mb-md-0"><label id="label_13">Service name <font color="red"><i class="fa fa-star fa-1"></i></font></label> <input type="text" class="form-control" name="field_13" placeholder="Enter Here" required=""></div>
<div class="col-md-4 mb-3 mb-md-0"><label id="label_6">Email ID </label> <input type="email" class="form-control" name="field_6" placeholder="Enter Here"></div>
<div class="col-md-4 mb-3 mb-md-0"><label id="label_9">Your Message <font color="red"><i class="fa fa-star fa-1"></i></font></label> <textarea class="form-control" name="field_9" placeholder="Enter Here" required=""></textarea></div>
</div>
<div class="row form-group">
<div class="col-md-12 mb-3 mb-md-0">
<div class="form-group submitBtn" align="right">
<button style="font-family: Lobster; background: rgb(0, 0, 0); color: rgb(255, 255, 255);" class="theme-btn btn-style-one btn">Submit</button>
</div>
</div>
</div>
</form>https://html.commonsupport.xyz/html/charity-club/inc/sendemail.php
<form action="https://html.commonsupport.xyz/html/charity-club/inc/sendemail.php" class="contact-form" id="footer-cf">
<input type="text" name="name" placeholder="Full Name">
<input type="text" name="email" placeholder="Email Address">
<textarea name="message" placeholder="Your Message"></textarea>
<button type="submit">Send</button>
</form>POST #
<form method="post" action="#">
<!--Form Portlet-->
<div class="form-portlet">
<h3>How Much Would you like to Donate?</h3>
<div class="row clearfix">
<div class="form-group col-lg-7 col-md-12 col-xs-12 clearfix">
<div class="radio-select">
<input type="radio" name="sel-amount" id="amount-1">
<label for="amount-1">$10</label>
</div>
<div class="radio-select">
<input type="radio" name="sel-amount" id="amount-2" checked="">
<label for="amount-2">$25</label>
</div>
<div class="radio-select">
<input type="radio" name="sel-amount" id="amount-3">
<label for="amount-3">$50</label>
</div>
<div class="radio-select">
<input type="radio" name="sel-amount" id="amount-4">
<label for="amount-4">$100</label>
</div>
<div class="radio-select">
<input type="radio" name="sel-amount" id="amount-5">
<label for="amount-5">$150</label>
</div>
</div>
<div class="form-group other-amount col-lg-5 col-md-8 col-xs-12 padd-top-10">
<input type="text" name="other-amount" value="" placeholder="Or Other Amount">
</div>
</div>
</div>
<br>
<!--Form Portlet-->
<div class="form-portlet">
<h4>Billing Information</h4>
<div class="row clearfix">
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">First Name <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="First Name" required="">
</div>
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Last Name <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="Last Name" required="">
</div>
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Email <span class="required">*</span></div>
<input type="email" name="name" value="" placeholder="Email" required="">
</div>
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Phone <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="Phone" required="">
</div>
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Address 1 <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="Address 1" required="">
</div>
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Address 2 <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="Address 2" required="">
</div>
</div>
</div>
<br>
<!--Form Portlet-->
<div class="form-portlet">
<h4>Payment Information</h4>
<div class="payment-option-logo"><img class="img-responsive" src="images/resource/payment-logos.png" alt=""></div>
<br>
<div class="row clearfix">
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Card Number <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="Card Number" required="">
</div>
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Card Holder Name <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="Card Holder Name" required="">
</div>
<div class="form-group col-lg-3 col-md-3 col-xs-12">
<div class="field-label">Expire Date <span class="required">*</span></div>
<select>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select>
</div>
<div class="form-group col-lg-3 col-md-3 col-xs-12">
<div class="field-label"> </div>
<select>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
</select>
</div>
<div class="form-group col-lg-6 col-md-6 col-xs-12">
<div class="field-label">Security Code (CVC) <span class="required">*</span></div>
<input type="text" name="name" value="" placeholder="Security Code" required="">
</div>
</div>
</div>
<div class="text-left"><button type="submit" class="theme-btn btn-style-two">Donate Now</button></div>
</form>Text Content
EMAIL prmpwa@gmail.com Call Now 919832253924 * Home * About Us * Photo Gallery * Our Services * Contact Us * * * My page WELCOME TO As a member of [Medical Association Name], you gain access to a wide range of exclusive benefits tailored to support your professional growth and success. These benefits include: Learn more PROGRESSIVE RURAL MEDICAL PRACTITIONERS WELFARE ASSOCIATION SUNLIMETECH This is basic card with image on top, title, description and button. SUNLIMETECH This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button. * * * * SUNLIMETECH This is basic card with image on top, title, description and button. SUNLIMETECH This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button. * * * * SUNLIMETECH This is basic card with image on top, title, description and button. SUNLIMETECH This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button. * * * * SUNLIMETECH This is basic card with image on top, title, description and button. SUNLIMETECH This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button. * * * * SUNLIMETECH This is basic card with image on top, title, description and button. SUNLIMETECH This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button. * * * * SUNLIMETECH This is basic card with image on top, title, description and button. SUNLIMETECH This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button.This is basic card with image on top, title, description and button. * * * * PROGRESSIVE RURAL MEDICAL PRACTITIONERS WELFARE ASSOCIATION Lorem ipsum dolor some link sit amet, cum at inani interesset At PROGRESSIVE RURAL MEDICAL PRACTITIONERS WELFARE ASSOCIATION], we are committed to advancing the field of medicine, fostering professional development, and promoting excellence in patient care. As a member of our esteemed association, you are part of a vibrant community of healthcare professionals dedicated to upholding the highest standards of medical practice. * Charity For Education * Home for homeless * Feed for hungry child * Clean water for people GET INVOLVED We encourage our members to actively participate in the activities and initiatives of [Medical Association Name]. Whether you are interested in volunteering, serving on committees, or contributing to our publications, your involvement strengthens our collective impact and furthers our mission. OUR MISSION Our mission is to provide support, resources, and advocacy for healthcare professionals at every stage of their careers. We strive to promote collaboration, innovation, and evidence-based medicine to enhance the health and well-being of individuals and communities worldwide. OUR GOAL There are many variations of passages of Lorem real lypsum available, but the in the majority have suffered alteration in some form, by injected humour, or lipuan domised words which don't look evenIpsum, you need to be sure there isn't theanything embarrassing hidden in the lorem middle of simply lorem dummy text. Our Services Form Name Address City State Pincode Contact no. Service name Email ID Your Message Submit PROGRESSIVE RURAL MEDICAL PRACTITIONERS WELFARE ASSOCIATION * Office Address: Anand Plaza, 3rd Floor Room No-10, Purulia (W.B. * +919832253924 * prmpwa@gmail.com QUICK LINKS USEFULL LINKS * Home * About Us * Photo Gallery * Our Services * Contact Us CONTACT FORM Send Copyright 2024 © P.R.M.P.W.A with love HOW MUCH WOULD YOU LIKE TO DONATE? $10 $25 $50 $100 $150 BILLING INFORMATION First Name * Last Name * Email * Phone * Address 1 * Address 2 * PAYMENT INFORMATION Card Number * Card Holder Name * Expire Date * 01 02 03 04 05 06 07 08 09 10 11 12 2016 2017 2018 2019 2020 Security Code (CVC) * Donate Now Close Download Close