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homerevitalize.cloud Open in urlscan Pro
162.213.249.49  Public Scan

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Submitted URL: https://medicarecover.care/
Effective URL: https://homerevitalize.cloud/form.php?sitename=eliteinfotech&leadtype=101&vid=25
Submission: On August 24 via automatic, source certstream-suspicious — Scanned from DE

Form analysis 1 forms found in the DOM

Name: theForm — POST data.php

<form action="data.php" method="post" name="theForm" id="theForm" novalidate="novalidate">
  <input id="sitename" name="sitename" type="hidden" value="eliteinfotech">
  <input id="leadtype" name="leadtype" type="hidden" value="101">
  <input type="hidden" name="vid" value="25">
  <input type="hidden" name="istest" value="">
  <input type="hidden" name="url" value="https://homerevitalize.cloud/form.php">
  <input type="hidden" name="browser" value="Mozilla/5.0 (X11; Linux x86_64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/128.0.0.0 Safari/537.36">
  <input type="hidden" name="agentid" value="">
  <input type="hidden" class="required" name="ipaddress" value="138.199.38.132">
  <div class="form-row">
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="firstName" placeholder="Your firstName" data-validation-required-message="Please enter First name">
      <p class="help-block text-danger"></p>
    </div>
    <div class="col-sm-2 control-group"> </div>
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="lastName" placeholder="Your lastName" data-validation-required-message="Please enter lastName">
      <p class="help-block text-danger"></p>
    </div>
  </div>
  <div class="form-row">
    <div class="col-sm-5 control-group">
      <input type="email" class="form-control bg-secondary border-0 py-4 px-3" name="email" placeholder="Your email" data-validation-required-message="Please enter email">
      <p class="help-block text-danger"></p>
    </div>
    <div class="col-sm-2 control-group"> </div>
    <div class="col-sm-5 control-group">
      <input type="tel" class="form-control bg-secondary border-0 py-4 px-3" name="phone" placeholder="Your phone" data-validation-required-message="Please enter phone" maxlength="10">
      <p class="help-block text-danger"></p>
    </div>
  </div>
  <div class="form-row">
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="address" placeholder="Your address" data-validation-required-message="Please enter address">
      <p class="help-block text-danger"></p>
    </div>
    <div class="col-sm-2 control-group"> </div>
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="city" placeholder="Your city" data-validation-required-message="Please enter city">
      <p class="help-block text-danger"></p>
    </div>
  </div>
  <div class="form-row">
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="state" placeholder="Your state" data-validation-required-message="Please enter state">
      <p class="help-block text-danger"></p>
    </div>
    <div class="col-sm-2 control-group"> </div>
    <div class="col-sm-5 control-group">
      <input type="tel" class="form-control bg-secondary border-0 py-4 px-3" name="zip" placeholder="Your zip" data-validation-required-message="Please enter zip" maxlength="5">
      <p class="help-block text-danger"></p>
    </div>
  </div>
  <div class="form-row">
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="roofType" placeholder="Your roofType" data-validation-required-message="Please enter roofType">
      <p class="help-block text-danger"></p>
    </div>
    <div class="col-sm-2 control-group"> </div>
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="propertyType" placeholder="Your propertyType" data-validation-required-message="Please enter propertyType">
      <p class="help-block text-danger"></p>
    </div>
  </div>
  <div class="form-row">
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="projectType" placeholder="Your projectType" data-validation-required-message="Please enter projectType">
      <p class="help-block text-danger"></p>
    </div>
    <div class="col-sm-2 control-group"> </div>
    <div class="col-sm-5 control-group">
      <input type="text" class="form-control bg-secondary border-0 py-4 px-3" name="universalLeadid" id="leadid_token" readonly="" placeholder="Universal Lead Id">
      <p class="help-block text-danger"></p>
    </div>
  </div>
  <div class="form-row">
    <div class="col-md-1"></div>
    <div class="col-md-12">
      <label class="checkbox">
        <p id="p1"><input type="checkbox" id="leadid_tcpa_disclosure" style="height: auto;width:auto;margin-bottom: 0rem;" name="AgreeWith" value="1" checked="">&nbsp; By clicking Submit, I agree to receive text messages. I provide my signature
          expressly consenting to recurring contact "for marketing purposes" at the number I provided regarding products or services via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may
          impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I can revoke this consent "at any time" by replying STOP to the text msg received.
          <a href="terms.php" target="_blank" style="color: blue;">Terms conditions</a> / <a href="privacy.php" target="_blank" style="color: blue;">privacy policy</a> apply. Msg data rates may apply.</p>
      </label>
    </div>
  </div>
  <div class="text-">
    <button class="btn btn-primary submit font-weight-bold py-3 px-5" id="quote-btn" type="button" name="sendMessageButton">submit</button>
  </div>
  <input type="hidden" name="Trusted_Form_URL" value="https://cert.trustedform.com/3b22bef23ca317338755e794d8e8b6e895de0f17" id="Trusted_Form_URL_0"><input type="hidden" name="xxTrustedFormToken"
    value="https://cert.trustedform.com/3b22bef23ca317338755e794d8e8b6e895de0f17" id="xxTrustedFormToken_0"><input type="hidden" name="xxTrustedFormPingUrl"
    value="https://ping.trustedform.com/0.buguInirF3OBh6iQtqZ9Jx2Gbz1yHrhkQfbb4fSFXwhP8y-KvQufCkzwJlsvu01tCyR8oYU._qvxmAFYsDF8nv4P2biRGw.A90F6Fzfvw8NWDMwyq3bng" id="xxTrustedFormPingUrl_0">
</form>

Text Content

HOMEREVITALIZE

Home Privacy Terms & Conditions Partners Get A quote

HE STATE DATA NOT FOUND IN OUR DATABASE, IP ADDRESS: 138.199.38.132

  By clicking Submit, I agree to receive text messages. I provide my signature
expressly consenting to recurring contact "for marketing purposes" at the number
I provided regarding products or services via live, automated or prerecorded
telephone call, text message, or email. I understand that my telephone company
may impose charges on me for these contacts, and I am not required to enter into
this agreement as a condition of purchasing property, goods, or services. I can
revoke this consent "at any time" by replying STOP to the text msg received.
Terms conditions / privacy policy apply. Msg data rates may apply.

submit

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