respond.ccs.co.za Open in urlscan Pro
41.164.141.27  Public Scan

Form analysis
1 forms found in the DOM

Name: frmProcessEmails — POST //respond.ccs.co.za/home.php?method=script&module=index&action=index

<form name="frmProcessEmails" id="frmProcessEmails" method="POST" action="//respond.ccs.co.za/home.php?method=script&amp;module=index&amp;action=index">
  <input type="hidden" class="" name="id" id="id" value="363614429">
  <input type="hidden" class="" name="hash" id="hash" value="a1ded834">
  <input type="hidden" class="" name="emailShotId" id="emailShotId" value="257597">
  <input type="hidden" class="" name="dealerId" id="dealerId" value="573">
  <div class="form-group row" style="margin:5px !important;">
    <div class="alert" role="alert" style="margin-left: auto;margin-right: auto">
      <h2 class="alert-heading" style="color:white;">SUBMIT MY ENQUIRY</h2>
      <p style="font-size:12px;color:#fff;">Thank you for getting in touch. Please complete the form below so that we can assist you as best we can.</p>
      <hr style="background-color:#fff;">
      <p class="mb-0" style="font-size:12px;color:#fff;">Please ensure that all details are correct before submitting.</p>
    </div>
  </div>
  <div class="form-group row">
    <label for="txtFirstname" class="col-sm-12 col-md-12 col-lg-12 text-left" style="font-size:14px;color:#fff;">First Name <span class="red">*</span></label>
    <div class="col-sm-12 col-md-12 col-lg-12">
      <input type="text" class="form-control validate['required']" name="txtFirstname" id="txtFirstname" value="Matimba">
    </div>
  </div>
  <div class="form-group row">
    <label for="txtSurname" class="col-sm-12 col-md-12 col-lg-12 text-left" style="font-size:14px;color:#fff;">Surname <span class="red">*</span></label>
    <div class="col-sm-12 col-md-12 col-lg-12">
      <input type="text" class="form-control validate['required']" name="txtSurname" id="txtSurname" value="Ntshani">
    </div>
  </div>
  <div class="form-group row">
    <label for="txtEmail" class="col-sm-12 col-md-12 col-lg-12 text-left" style="font-size:14px;color:#fff;">Email Address <span class="red">*</span></label>
    <div class="col-sm-12 col-md-12 col-lg-12">
      <input type="text" class="form-control validate['required','email']" name="txtEmail" id="txtEmail" value="matimba.ntshani@crbard.com">
    </div>
  </div>
  <div class="form-group row">
    <label for="txtCellNumber" class="col-sm-12 col-md-12 col-lg-12 text-left" style="font-size:14px;color:#fff;">Mobile <span class="red">*</span></label>
    <div class="col-sm-12 col-md-12 col-lg-12">
      <input type="text" class="form-control validate['required','phone']" name="txtCellNumber" id="txtCellNumber" value="0737831797">
    </div>
  </div><input type="hidden" class="" name="enquiryType" id="enquiryType" value="1-2">
  <div class="form-group row">
    <label for="selEnquiryType" class="col-sm-12 col-md-12 col-lg-12 text-left" style="font-size:14px;color:#fff;">Comments <span class="red">*</span></label>
    <div class="col-sm-12 col-md-12 col-lg-12">
      <textarea class="form-control" name="taResponse" id="taResponse" rows="5"></textarea>
    </div>
  </div>
  <div class="form-group row">
    <div class="col-sm-12 col-md-12">
      <input type="submit" class="btn onButtonHover" name="btnSubmit" id="btnSubmit" value="Submit" style="font-size:14px;width:100%;color:rgba(0,0,0,0.4);background-color:white">
    </div>
  </div>
</form>

Text Content

SUBMIT MY ENQUIRY

Thank you for getting in touch. Please complete the form below so that we can
assist you as best we can.

--------------------------------------------------------------------------------

Please ensure that all details are correct before submitting.

First Name *

Surname *

Email Address *

Mobile *

Comments *