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2a02:26f0:9b00:391::4213  Public Scan

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Submitted URL: https://www.retoure.pzn24.de/
Effective URL: https://www.dhl.de/dhl-rpi/gw/rpcustomerweb/OrderAnon.action?__userlocale=DE&__gwfs=4774859484148659159
Submission: On March 15 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

Name: form — POST /dhl-rpi/gw/rpcustomerweb/OrderAnon.action

<form method="post" name="form" action="/dhl-rpi/gw/rpcustomerweb/OrderAnon.action" id="form">
  <section class="mm_section mm_section-primary">
    <div class="panel panel-default">
      <div class="panel-body">
        <div class="text-center">
          <div class="dhl redesign headline">
            <h3>Retourenlabel erstellen</h3>
            <h5>Ihr Rückversand an MediPark Apotheke OHG</h5>
          </div>
        </div>
        <div class="row">
          <div class="col-xs-5 col-md-6">
            <div class="form-group">
              <label for="languageSelector.selectedLanguage">Bitte wählen Sie eine Sprache aus. </label>
              <div class="dropdown-helper">
                <select tabindex="-1" name="languageSelector.selectedLanguage" onchange="ok2('onChangeLanguage', 'form')" id="languageSelector.selectedLanguage" class="mm_select2">
                  <option value="DE" selected="selected">Deutsch</option>
                  <option value="EN">English</option>
                  <option value="FR">Français</option>
                  <option value="DA">Dansk</option>
                </select>
              </div>
            </div>
          </div>
          <div class="col-xs-7 col-md-offset-3 col-md-3">
          </div>
        </div>
        <div class="row feedback">
          <div class="col-xs-12">
          </div>
        </div>
        <div class="row">
          <div class="col-xs-12 col-md-9">
            <h6>Bitte tragen Sie Ihre Absenderdetails in die folgenden Felder ein und klicken Sie auf "Weiter".</h6>
          </div>
          <div class="col-xs-12 col-md-3">
            <p class="pull-right"><small>* Pflichtfeld</small></p>
          </div>
        </div>
        <div class="form-inline">
          <div class="form-group">
            <label for="shipment.customerReference"> Kundenreferenz </label>
            <input name="shipment.shipment.customerReference" placeholder="Optional, wird auf dem Retourenlabel ausgegeben" id="shipment.shipment.customerReference" type="text" class="form-control" value="" maxlength="30">
          </div>
        </div>
        <!-- eval show country -->
        <div class="form-inline">
          <div class="form-group">
            <label for="shipment.senderAddress.name1">Vorname und Nachname*</label><input name="shipment.senderAddress.name1" placeholder="Pflichtfeld zur Erfassung des Absenders" id="shipment.senderAddress.name1" type="text"
              class="mm_required form-control" value="" maxlength="50">
          </div>
        </div>
        <div class="form-inline">
          <div class="form-group">
            <label for="shipment.senderAddress.name2">Namenszusatz 1</label><input name="shipment.senderAddress.name2" placeholder="Optional für Namenszusätze" id="shipment.senderAddress.name2" type="text" class="form-control" value=""
              maxlength="50">
          </div>
        </div>
        <div class="form-inline">
          <div class="form-group">
            <label for="shipment.senderAddress.name3">Namenszusatz 2</label><input name="shipment.senderAddress.name3" placeholder="Optional für Namenszusätze" id="shipment.senderAddress.name3" type="text" class="form-control" value=""
              maxlength="50">
          </div>
        </div>
        <div class="row">
          <div class="col-xs-12">
            <div class="row mm_small_padding">
              <div class="col-xs-8 col-md-9">
                <div class="form-group">
                  <label for="shipment.senderAddress.street">Straße*</label><input name="shipment.senderAddress.street" placeholder="Pflichtfeld für Absenderstraße" id="shipment.senderAddress.street" type="text" class="mm_required form-control"
                    value="" maxlength="70">
                </div>
              </div>
              <div class="col-xs-4 col-md-3">
                <div class="form-group">
                  <label for="shipment.senderAddress.streetNumber">Nr.*</label><input name="shipment.senderAddress.streetNumber" placeholder="Hausnr." id="shipment.senderAddress.streetNumber" type="text" class="mm_required form-control" value=""
                    maxlength="15">
                </div>
              </div>
            </div>
          </div>
        </div>
        <div class="row">
          <div class="col-xs-12">
            <div class="row mm_small_padding">
              <div class="col-xs-4 col-md-3">
                <div class="form-group">
                  <label for="shipment.senderAddress.plz">PLZ*</label><input maxlength="5" name="shipment.senderAddress.plz" placeholder="Postleitzahl" id="shipment.senderAddress.plz" type="text" class="mm_required form-control" value="">
                </div>
              </div>
              <div class="col-xs-8 col-md-9">
                <div class="form-group">
                  <label for="shipment.senderAddress.city">Ort*</label><input name="shipment.senderAddress.city" placeholder="Pflichtfeld für den Absendeort." id="shipment.senderAddress.city" type="text" class="mm_required form-control" value=""
                    maxlength="50">
                </div>
              </div>
            </div>
          </div>
        </div>
        <div class="form-inline">
          <div class="form-group">
            <label>Land</label>
            <input name="shipment.senderAddress.country" disabled="disabled" id="shipment.senderAddress.country" type="text" class="form-control" value="Deutschland" maxlength="3">
          </div>
        </div>
        <script type="text/javascript">
          $(document).ready(function() {
            initPlzAutocomplete('#shipment.senderAddress.plz', '#shipment.senderAddress.city', 'DEU');
          });
        </script>
        <div class="row">
        </div>
        <input type="hidden" name="__gwfs" value="4774859484148659159">
        <input type="hidden" id="eventTrigger">
        <div class="row">
          <div class="col-xs-6">
            <div class="form-group">
              <label for="orderEmail">E-Mail</label><input name="orderEmail" placeholder="Optionale Angabe für die zusätzliche Bereitstellung des Retourenlabels" id="orderEmail" type="text" class="form-control">
            </div>
          </div>
          <div class="col-xs-6">
            <div class="form-group">
              <label>Sprache der E-Mail</label>
              <div class="dropdown-helper">
                <select name="emailLanguageSelector.selectedLanguage" id="emailLanguageSelector.selectedLanguage" class="mm_select2">
                  <option value="DE" selected="selected">Deutsch</option>
                  <option value="EN">English</option>
                  <option value="FR">Français</option>
                  <option value="DA">Dansk</option>
                </select>
              </div>
            </div>
          </div>
        </div>
        <!-- RETO-57 -->
      </div>
    </div>
  </section>
  <section class="mm_section mm_section-secondary">
    <div class="mm_buttons mm_buttons-full-width">
      <a href="javascript:void(0)" id="onClearShipment" onclick="ok('onClearShipment')" class="btn btn-default">Felder leeren</a>
      <button name="onOrder" id="onSave" type="submit" class="btn btn-primary">Weiter</button>
    </div>
  </section>
  <div style="display: none;"><input type="hidden" name="_sourcePage" value="lxEX88vh97nBu4hWn5z7eRzbudkfY94vRePrl8qf0YpzCRLZG151cDFJKzsO6qHdqaVwwBYoegVM5okqVihHMFfkevVVZnXeW3vYebraO1gnnO-Y5oi-fg=="><input type="hidden" name="__gwfs"
      value="4774859484148659159"><input type="hidden" name="__fp" value="SWBOTrds5ZtrpsGN2Yp8EXA1PBMIK97Q9StBskeycZojLOTxeXKeWTbKG9RNwjAYgNryKpOIjoVulSTwET7KRwACXrc4DJl1q5LLl05NWM1oeUKdjGXvohMPkV6cLT9WK4nw7pN43vpnoXubBOGBXvS_fpymoa22"></div>
</form>

Text Content

RETOURENLABEL ERSTELLEN

IHR RÜCKVERSAND AN MEDIPARK APOTHEKE OHG

Bitte wählen Sie eine Sprache aus.
DeutschEnglishFrançaisDansk



BITTE TRAGEN SIE IHRE ABSENDERDETAILS IN DIE FOLGENDEN FELDER EIN UND KLICKEN
SIE AUF "WEITER".

* Pflichtfeld

Kundenreferenz
Vorname und Nachname*
Namenszusatz 1
Namenszusatz 2
Straße*
Nr.*
PLZ*
Ort*
Land

E-Mail
Sprache der E-Mail
DeutschEnglishFrançaisDansk
Felder leeren Weiter


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