researchstudytrial.com Open in urlscan Pro
52.222.236.12  Public Scan

Form analysis
1 forms found in the DOM

POST https://researchstudytrial.com/register/complete-registration

<form action="https://researchstudytrial.com/register/complete-registration" method="post" class="form-horizontal"><input type="hidden" name="_token" value="OXZs0MLmnZlWpqKwVygWAN1LL0sCCk7910xfYlCg">
  <div class="row">
    <div class="col-md-8 col-md-offset-2">
      <div class="panel panel-default">
        <div class="panel panel-warning">
          <div class="panel-heading">
            <h3 class="panel-title">Password must be at least 10 characters, contain at least one upper case letter, one lower case letter, one number and one of the following !@#$%^&amp;* characters.</h3>
          </div>
        </div>
        <div class="panel-heading">Set Password</div>
        <div class="panel-body">
          <div class="form-group"><label for="password" class="col-md-4 control-label">Password*</label>
            <div class="col-md-6"><input id="password" type="password" name="password" required="required" class="form-control"></div>
          </div>
          <div class="form-group"><label for="password-confirm" class="col-md-4 control-label">Confirm Password*</label>
            <div class="col-md-6"><input id="password-confirm" type="password" name="password_confirmation" required="required" class="form-control"></div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col-md-8 col-md-offset-2">
      <div class="panel panel-default">
        <div class="panel-heading">Site Coordinator Contact</div>
        <div class="panel-body">
          <div class="form-group"><label for="email" class="col-md-4 control-label">Email</label>
            <div class="col-md-6"><input name="email" type="email" id="email" placeholder="Email*" value="alevi@chla.usc.edu" disabled="disabled" class="form-control"></div>
          </div>
          <div class="form-group"><label for="first_name" class="col-md-4 control-label">First Name*</label>
            <div class="col-md-6"><input name="first_name" type="text" id="first_name" placeholder="First Name" value="" class="form-control"></div>
          </div>
          <div class="form-group"><label for="last_name" class="col-md-4 control-label">Last Name*</label>
            <div class="col-md-6"><input name="last_name" type="text" id="last_name" placeholder="Last Name" value="" class="form-control"></div>
          </div>
          <div class="form-group"><label for="primary_phone" class="col-md-4 control-label">Primary Phone*</label>
            <div class="col-md-6"><input name="primary_phone" type="text" id="primary_phone" placeholder="Primary Phone" value="" class="form-control"></div>
          </div>
          <div class="form-group"><label for="secondary_phone" class="col-md-4 control-label">Secondary Phone</label>
            <div class="col-md-6"><input name="secondary_phone" type="text" id="secondary_phone" placeholder="Secondary Phone" value="" class="form-control"></div>
          </div>
          <div class="form-group"><label for="fax" class="col-md-4 control-label">Fax Number</label>
            <div class="col-md-6"><input name="fax" type="text" id="fax" placeholder="Fax Number" value="" class="form-control"></div>
          </div>
          <div class="form-group">
            <div class="col-md-8 col-md-offset-2"><button type="submit" class="btn btn-primary pull-right"> Complete Registration </button></div>
          </div>
        </div>
      </div>
    </div>
  </div>
</form>

Text Content

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PASSWORD MUST BE AT LEAST 10 CHARACTERS, CONTAIN AT LEAST ONE UPPER CASE LETTER,
ONE LOWER CASE LETTER, ONE NUMBER AND ONE OF THE FOLLOWING !@#$%^&* CHARACTERS.

Set Password
Password*

Confirm Password*

Site Coordinator Contact
Email

First Name*

Last Name*

Primary Phone*

Secondary Phone

Fax Number

Complete Registration