service-ac.rajajayateknik.id Open in urlscan Pro
103.59.160.158  Public Scan

Form analysis
1 forms found in the DOM

POST https://service-ac.rajajayateknik.id/public/user/store-order

<form action="https://service-ac.rajajayateknik.id/public/user/store-order" method="POST">
  <input type="hidden" name="_token" value="A3H6n3uGFocj8apPmVPWJUOUm62rNtLym4qzvYVa">
  <div class="mb-16">
    <input type="text" name="name" id="" class="form-control" placeholder="Masukan Nama Anda">
  </div>
  <div class="mb-16">
    <input type="number" name="phone_number" id="" class="form-control" placeholder="Masukan Nomor Telphone Anda">
  </div>
  <!--<div class="mb-3">
                                                <input
                                                    type="text"
                                                    name="googlemap"
                                                    class="form-control"
                                                    placeholder="Masukkan Link Google Map Anda"
                                                />
                                                <small class="text-danger">Catatan: Ini adalah opsional, Anda dapat mengisi atau tidak.</small>

                                            </div>-->
  <div class="mb-30">
    <textarea placeholder="Masukan Alamat Lengkap Anda!" name="alamat" id="" cols="30" rows="3" class="form-control"></textarea>
  </div>
  <div class="mb-30">
    <textarea placeholder="Masukan Permasalahan Anda!" name="problem_description" id="problem_description" cols="30" rows="5" class="form-control"></textarea>
  </div>
  <button type="submit" class="w-100 btn btn-primary">Tambahkan</button>
</form>

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