www.dream-singles.com
Open in
urlscan Pro
54.201.118.129
Public Scan
Submitted URL: https://www.dream-singles.com/emailLogin?dm_id=3953162548&dm_key=9427c49fb873573ced2694847db518e0&key=MTAwOTk5NzkgMTY2NzYzNjA4...
Effective URL: https://www.dream-singles.com/contact_us.php
Submission: On October 06 via api from BE — Scanned from DE
Effective URL: https://www.dream-singles.com/contact_us.php
Submission: On October 06 via api from BE — Scanned from DE
Form analysis 2 forms found in the DOM
Name: request — POST
<form name="request" method="post" enctype="multipart/form-data">
<div class="row">
<div class="col-sm-4 form-label"><label for="request_sender" class="required">First Name</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_sender" name="request[sender]" required="required" class="ds-input form-control" value="Willy">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_lastName" class="required">Last Name</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_lastName" name="request[lastName]" required="required" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_email" class="required">Email</label></div>
<div class="col-sm-8 form-input">
<input type="email" id="request_email" name="request[email]" required="required" class="ds-input form-control" value="willy.a.maes@telenet.be">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_phone_number">Phone</label></div>
<div class="col-sm-8">
<div class="row">
<div class="col-xs-4 form-input">
<div class="dropdown bootstrap-select form-control bs3"><select id="request_country" name="request[country]" class="form-control" tabindex="-98">
<option value="5002">AU +61</option>
<option value="5004">BE +32</option>
<option value="5001">CA +1</option>
<option value="5029">DK +45</option>
<option value="5033">FR +33</option>
<option value="5063">NO +47</option>
<option value="5087">SE +46</option>
<option value="5094">GB +44</option>
<option value="5000">US +1</option>
<option disabled="disabled">-------------------</option>
<option value="5010">AF +93</option>
<option value="5012">AL +355</option>
<option value="5013">DZ +213</option>
<option value="5112">AS +1 684</option>
<option value="5113">AD +376</option>
<option value="5014">AO +244</option>
<option value="5114">AI +1 264</option>
<option value="8">AQ </option>
<option value="5015">AG +1268</option>
<option value="5011">AR +54</option>
<option value="5017">AM +374</option>
<option value="5018">AW +297</option>
<option value="5002">AU +61</option>
<option value="5003">AT +43</option>
<option value="5115">AZ +994</option>
<option value="5019">BS +1 242</option>
<option value="5116">BH +973</option>
<option value="5020">BD +880</option>
<option value="5005">BB +1 246</option>
<option value="5110">BY +375</option>
<option value="5004" selected="selected">BE +32</option>
<option value="5117">BZ +501</option>
<option value="5118">BJ +229</option>
<option value="5008">BM +1 441</option>
<option value="5119">BT +975</option>
<option value="5109">BO +591</option>
<option value="5009">BA +387</option>
<option value="5120">BW +267</option>
<option value="29">BV </option>
<option value="5006">BR +55</option>
<option value="31">IO +246</option>
<option value="5122">BN +673</option>
<option value="5007">BG +359</option>
<option value="5123">BF +226</option>
<option value="5125">BI +257</option>
<option value="5021">KH +855</option>
<option value="5126">CM +237</option>
<option value="5001">CA +1</option>
<option value="5127">CV +238</option>
<option value="5022">KY + 345</option>
<option value="5128">CF +236</option>
<option value="5129">TD +235</option>
<option value="5023">CL +56</option>
<option value="5024">CN +86</option>
<option value="5130">CX +61</option>
<option value="5131">CC +61</option>
<option value="5025">CO +57</option>
<option value="5132">KM +269</option>
<option value="5133">CG +242</option>
<option value="5135">CK +682</option>
<option value="5026">CR +506</option>
<option value="52">CI +225</option>
<option value="5027">HR +385</option>
<option value="5137">CU +53</option>
<option value="5028">CY +537</option>
<option value="5108">CZ +420</option>
<option value="5029">DK +45</option>
<option value="5138">DJ +253</option>
<option value="5139">DM +1 767</option>
<option value="5140">DO +1 849</option>
<option value="61">TP </option>
<option value="5036">EC +593</option>
<option value="5030">EG +20</option>
<option value="5141">SV +503</option>
<option value="5142">GQ +240</option>
<option value="5143">ER +291</option>
<option value="5031">EE +372</option>
<option value="5144">ET +251</option>
<option value="5145">FK +500</option>
<option value="5146">FO +298</option>
<option value="5147">FJ +679</option>
<option value="5032">FI +358</option>
<option value="5033">FR +33</option>
<option value="74">FX </option>
<option value="5148">GF +594</option>
<option value="5149">PF +689</option>
<option value="77">TF </option>
<option value="5150">GA +241</option>
<option value="5151">GM +220</option>
<option value="5152">GE +995</option>
<option value="5034">DE +49</option>
<option value="5101">GH +233</option>
<option value="5153">GI +350</option>
<option value="5035">GR +30</option>
<option value="5037">GL +299</option>
<option value="5154">GD +1 473</option>
<option value="5155">GP +590</option>
<option value="5038">GU +1 671</option>
<option value="5156">GT +502</option>
<option value="5158">GN +224</option>
<option value="5159">GW +245</option>
<option value="5160">GY +595</option>
<option value="5161">HT +509</option>
<option value="94">HM </option>
<option value="5162">HN +504</option>
<option value="5039">HK +852</option>
<option value="5040">HU +36</option>
<option value="5041">IS +354</option>
<option value="5042">IN +91</option>
<option value="5043">ID +62</option>
<option value="5103">IR +98</option>
<option value="5163">IQ +964</option>
<option value="5044">IE +353</option>
<option value="5045">IL +972</option>
<option value="5047">IT +39</option>
<option value="5048">JM +1 876</option>
<option value="5049">JP +81</option>
<option value="5050">JO +962</option>
<option value="5165">KZ +7 7</option>
<option value="5051">KE +254</option>
<option value="5166">KI +686</option>
<option value="5167">KP +850</option>
<option value="5052">KR +82</option>
<option value="5053">KW +965</option>
<option value="5168">KG +996</option>
<option value="116">LA +856</option>
<option value="5054">LV +371</option>
<option value="5056">LB +961</option>
<option value="5170">LS +266</option>
<option value="5171">LR +231</option>
<option value="121">LY +218</option>
<option value="5173">LI +423</option>
<option value="5055">LT +370</option>
<option value="5174">LU +352</option>
<option value="5175">MO +853</option>
<option value="5176">MK +389</option>
<option value="5177">MG +261</option>
<option value="5178">MW +265</option>
<option value="5057">MY +60</option>
<option value="5060">MV +960</option>
<option value="5179">ML +223</option>
<option value="5058">MT +356</option>
<option value="5181">MH +692</option>
<option value="5182">MQ +596</option>
<option value="5183">MR +222</option>
<option value="5184">MU +230</option>
<option value="5185">YT +262</option>
<option value="5059">MX +52</option>
<option value="5186">FM +691</option>
<option value="5187">MD +373</option>
<option value="5188">MC +377</option>
<option value="5189">MN +976</option>
<option value="5236">ME +382</option>
<option value="5190">MS +1664</option>
<option value="5107">MA +212</option>
<option value="5064">MZ +258</option>
<option value="146">MM +95</option>
<option value="5065">NA +264</option>
<option value="5191">NR +674</option>
<option value="5066">NP +977</option>
<option value="5061">NL +31</option>
<option value="5192">AN +599</option>
<option value="5193">NC +687</option>
<option value="5062">NZ +64</option>
<option value="5194">NI +505</option>
<option value="5195">NE +227</option>
<option value="5102">NG +234</option>
<option value="5196">NU +683</option>
<option value="5197">NF +672</option>
<option value="5198">MP +1 670</option>
<option value="5063">NO +47</option>
<option value="5067">OM +968</option>
<option value="5068">PK +92</option>
<option value="5199">PW +680</option>
<option value="5069">PA +507</option>
<option value="5200">PG +675</option>
<option value="5070">PY +595</option>
<option value="5071">PE +51</option>
<option value="5072">PH +63</option>
<option value="169">PN +872</option>
<option value="5073">PL +48</option>
<option value="5074">PT +351</option>
<option value="5075">PR +1 939</option>
<option value="5076">QA +974</option>
<option value="5201">RE +262</option>
<option value="5077">RO +40</option>
<option value="5078">RU +7</option>
<option value="5202">RW +250</option>
<option value="5204">KN +1 869</option>
<option value="5079">LC +1 758</option>
<option value="5206">VC +1 784</option>
<option value="5207">WS +685</option>
<option value="5208">SM +378</option>
<option value="5209">ST +239</option>
<option value="5080">SA +966</option>
<option value="5210">SN +221</option>
<option value="5235">RS +381</option>
<option value="5211">SC +248</option>
<option value="5212">SL +232</option>
<option value="5081">SG +65</option>
<option value="5105">SK +421</option>
<option value="5082">SI +386</option>
<option value="5213">SB +677</option>
<option value="5214">SO +252</option>
<option value="5083">ZA +27</option>
<option value="194">GS +500</option>
<option value="5084">ES +34</option>
<option value="5085">LK +94</option>
<option value="197">SH +290</option>
<option value="198">PM +508</option>
<option value="5215">SD +249</option>
<option value="200">SR +597</option>
<option value="5216">SJ +47</option>
<option value="5217">SZ +268</option>
<option value="5087">SE +46</option>
<option value="5088">CH +41</option>
<option value="5218">SY +963</option>
<option value="5089">TW +886</option>
<option value="5220">TJ +992</option>
<option value="5106">TZ +255</option>
<option value="5090">TH +66</option>
<option value="5221">TG +228</option>
<option value="5222">TK +690</option>
<option value="5223">TO +676</option>
<option value="5091">TT +1 868</option>
<option value="5224">TN +216</option>
<option value="5092">TR +90</option>
<option value="5225">TM +993</option>
<option value="5226">TC +1 649</option>
<option value="5227">TV +688</option>
<option value="5228">UG +256</option>
<option value="5093">UA +380</option>
<option value="5111">AE +971</option>
<option value="5094">GB +44</option>
<option value="5000">US +1</option>
<option value="224">UM </option>
<option value="5095">UY +598</option>
<option value="5229">UZ +998</option>
<option value="5230">VU +678</option>
<option value="5231">VA +379</option>
<option value="5096">VE +58</option>
<option value="5097">VN +84</option>
<option value="231">VG +1 284</option>
<option value="5232">VI +1 340</option>
<option value="5233">WF +681</option>
<option value="234">EH </option>
<option value="5234">YE +967</option>
<option value="237">ZR </option>
<option value="5098">ZM +260</option>
<option value="5099">ZW +263</option>
</select><button type="button" class="btn dropdown-toggle btn-default" data-toggle="dropdown" role="button" data-id="request_country" title="BE +32">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">BE +32</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
</div>
<div class="col-xs-8 form-input">
<input type="tel" id="request_phone_number" name="request[phone_number]" class="ds-input form-control">
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label class="required" for="request_type">Type of comment</label></div>
<div class="col-sm-8 form-input">
<div class="dropdown bootstrap-select ds-input form-control bs3"><select id="request_type" name="request[type]" class="ds-input form-control" tabindex="-98">
<option value="1">General</option>
<option value="2">Billing</option>
<option value="3">Suggestions</option>
<option value="4">Broken link</option>
<option value="6">Tech support</option>
<option value="7">Other</option>
<option value="8">Limited</option>
<option value="9">App</option>
<option value="10">Apartment</option>
<option value="11">Tours</option>
<option value="12">Affiliate</option>
</select><button type="button" class="btn dropdown-toggle btn-default" data-toggle="dropdown" role="button" data-id="request_type" title="General">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">General</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
<p class="billing">Thank you for contacting Dream-Singles.com Billing Inquiries Department, we look forward to assisting you and providing you with the best possible service and resolution. In order to be of better assistance to you provide the
following information:</p>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label class="required" for="request_priority">Priority</label></div>
<div class="col-sm-8 form-input">
<div class="dropdown bootstrap-select ds-input form-control bs3"><select id="request_priority" name="request[priority]" class="ds-input form-control" tabindex="-98">
<option value="1">Low</option>
<option value="2">Medium</option>
<option value="3">High</option>
<option value="4">Urgent</option>
</select><button type="button" class="btn dropdown-toggle btn-default" data-toggle="dropdown" role="button" data-id="request_priority" title="Low">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">Low</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_subject" class="required">Subject</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_subject" name="request[subject]" required="required" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label-textarea"><label for="request_content" class="required">Please explain your reason for this inquiry</label></div>
<div class="col-sm-8 form-input">
<textarea id="request_content" name="request[content]" required="required" class="ds-input form-control"></textarea>
</div>
</div>
<div class="billing">
<div class="row">
<div class="col-sm-4 form-label"><label for="request_alternate_phone">Alternate phone</label></div>
<div class="col-sm-8 form-input">
<input type="tel" id="request_alternate_phone" name="request[alternate_phone]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_reach_time">Best Time to Reach You</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_reach_time" name="request[reach_time]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_billing_address">entity.billingAddress</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_billing_address" name="request[billing_address]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_last_four">entity.lastFour</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_last_four" name="request[last_four]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_expiration">entity.expiration</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_expiration" name="request[expiration]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_name_bank_card">entity.nameBankCard</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_name_bank_card" name="request[name_bank_card]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_city">entity.city</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_city" name="request[city]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_charges_in_question">Charges in Question</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_charges_in_question" name="request[charges_in_question]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_date_of_charges">Date of Charges (MM/DD/YY)</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_date_of_charges" name="request[date_of_charges]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label class="" for="request_is_member">Are you a member of Dream-Singles.com?</label></div>
<div class="col-sm-8 form-input">
<div class="dropdown bootstrap-select ds-input form-control bs3"><select id="request_is_member" name="request[is_member]" class="ds-input form-control" tabindex="-98">
<option value=""></option>
<option value="1">Yes</option>
<option value="0">No</option>
</select><button type="button" class="btn dropdown-toggle btn-default bs-placeholder" data-toggle="dropdown" role="button" data-id="request_is_member" title="Nothing selected">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">Nothing selected</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_authorized_charges">Are there any charges that you've authorized?</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_authorized_charges" name="request[authorized_charges]" class="ds-input form-control">
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_vip">Are you a VIP member? Please provide your Driver's License or Photo ID #</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_vip" name="request[vip]" class="ds-input form-control">
</div>
</div>
</div>
<div class="technical">
<div class="row">
<div class="col-sm-4 form-label"><label for="request_operating_system">Operating System</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_operating_system" name="request[operating_system]" class="ds-input form-control">
<small id="request_operating_system_help" class="form-text text-muted">(e.g. Windows XP, Windows ME, Windows 8, Windows 10, etc.)</small>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_ram">RAM</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_ram" name="request[ram]" class="ds-input form-control">
<small id="request_ram_help" class="form-text text-muted">(e.g. 1GB RAM, 256MB RAM, etc.)</small>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_connection">Connection</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_connection" name="request[connection]" class="ds-input form-control">
<small id="request_connection_help" class="form-text text-muted">(e.g. dial-up, cable, satellite, etc.)</small>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_service_provider">Service provider</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_service_provider" name="request[service_provider]" class="ds-input form-control">
<small id="request_service_provider_help" class="form-text text-muted">(e.g. Spectrum, Verizon, etc.)</small>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_browser">Browser</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_browser" name="request[browser]" class="ds-input form-control">
<small id="request_browser_help" class="form-text text-muted">(e.g. Internet Explorer 10, Chrome, Firefox, etc.)</small>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_toolbars">Toolbars</label></div>
<div class="col-sm-8 form-input">
<input type="text" id="request_toolbars" name="request[toolbars]" class="ds-input form-control">
<small id="request_toolbars_help" class="form-text text-muted">(e.g. Google Toolbar, Yahoo Toolbar, etc.)</small>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_file1">Attach a file</label></div>
<div class="col-sm-8 form-input">
<div class="custom-file"><input type="file" id="request_file1" name="request[file1]" class="ds-input custom-file-input"><label for="request_file1" class="custom-file-label"></label>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_file2">Attach a file</label></div>
<div class="col-sm-8 form-input">
<div class="custom-file"><input type="file" id="request_file2" name="request[file2]" class="ds-input custom-file-input"><label for="request_file2" class="custom-file-label"></label>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-4 form-label"><label for="request_file3">Attach a file</label></div>
<div class="col-sm-8 form-input">
<div class="custom-file"><input type="file" id="request_file3" name="request[file3]" class="ds-input custom-file-input"><label for="request_file3" class="custom-file-label"></label>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-8 col-sm-offset-4 text-center">
<button type="submit" class="btn btn-primary submit">Submit</button>
</div>
</div>
<input type="hidden" id="request__token" name="request[_token]" value="JbM0dVqc3HDC6SkNMDejMTwPndHVCS5Oq6E3sqnqHPI">
</form>Name: membership_purchase — POST /members/membershipPlans
<form name="membership_purchase" method="post" action="/members/membershipPlans">
<fieldset class="form-group billing-information-form">
<div class="billing-wrapper">
<div class="billing-section">
<fieldset class="form-group billing-card-wrapper">
<label class="col-form-label required">Billing Address</label>
<div class="row">
<div class="col-12 col-xs-12">
<div class="form-group"><input type="text" id="membership_purchase_billing_BillingAddress_address" name="membership_purchase[billing][BillingAddress][address]" required="required" placeholder="Street Address" class="form-control"></div>
</div>
<div class="col-6 col-xs-6">
<div class="form-group"><input type="text" id="membership_purchase_billing_BillingAddress_zip" name="membership_purchase[billing][BillingAddress][zip]" required="required" placeholder="Zip Code" class="form-control"></div>
</div>
<div class="col-6 col-xs-6">
<div class="form-group"><input type="text" id="membership_purchase_billing_BillingAddress_city" name="membership_purchase[billing][BillingAddress][city]" required="required" placeholder="City" class="form-control"></div>
</div>
<div class="col-6 col-xs-6">
<div class="form-group">
<div class="dropdown bootstrap-select form-control bs3"><select id="membership_purchase_billing_BillingAddress_state" name="membership_purchase[billing][BillingAddress][state]" class="form-control" tabindex="-98">
<option value="" selected="selected">--- Select State ---</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="AL">Alabama</option>
<option value="AE">Armed Forces (AE)</option>
<option value="AA">Armed Forces (AA)</option>
<option value="AP">Armed Forces (AP)</option>
</select><button type="button" class="btn dropdown-toggle btn-default bs-placeholder" data-toggle="dropdown" role="button" data-id="membership_purchase_billing_BillingAddress_state" title="--- Select State ---">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">--- Select State ---</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
</div>
</div>
<div class="col-6 col-xs-6">
<div class="form-group">
<div class="dropdown bootstrap-select form-control bs3"><select id="membership_purchase_billing_BillingAddress_country" name="membership_purchase[billing][BillingAddress][country]" required="required" class="form-control"
tabindex="-98">
<option value="" selected="selected">Select Country</option>
<option value="5000">United States</option>
<option value="5094">United Kingdom</option>
<option value="5001">Canada</option>
<option value="5002">Australia</option>
<option value="5087">Sweden</option>
<option value="5029">Denmark</option>
<option value="5063">Norway</option>
<option value="5033">France</option>
<option value="5004">Belgium</option>
<option value="5047">Italy</option>
<optgroup label="All Countries">
<option value="5010">Afghanistan</option>
<option value="5012">Albania</option>
<option value="5013">Algeria</option>
<option value="5112">American Samoa</option>
<option value="5113">Andorra</option>
<option value="5014">Angola</option>
<option value="5114">Anguilla</option>
<option value="8">Antarctica</option>
<option value="5015">Antigua</option>
<option value="5011">Argentina</option>
<option value="5017">Armenia</option>
<option value="5018">Aruba</option>
<option value="5003">Austria</option>
<option value="5115">Azerbaijan</option>
<option value="5019">Bahamas</option>
<option value="5116">Bahrain</option>
<option value="5020">Bangladesh</option>
<option value="5005">Barbados</option>
<option value="5117">Belize</option>
<option value="5118">Benin</option>
<option value="5008">Bermuda</option>
<option value="5119">Bhutan</option>
<option value="5109">Bolivia</option>
<option value="5120">Botswana</option>
<option value="29">Bouvet Island</option>
<option value="5006">Brazil</option>
<option value="31">British Indian Ocean Territory</option>
<option value="5122">Brunei Darussalam</option>
<option value="5007">Bulgaria</option>
<option value="5123">Burkina Faso</option>
<option value="5021">Cambodia</option>
<option value="5126">Cameroon</option>
<option value="5127">Cape Verde</option>
<option value="5022">Cayman Islands</option>
<option value="5129">Chad</option>
<option value="5023">Chile</option>
<option value="5024">China</option>
<option value="5130">Christmas Island</option>
<option value="5131">Cocos (Keeling) Islands</option>
<option value="5025">Colombia</option>
<option value="5132">Comoros</option>
<option value="5135">Cook Islands</option>
<option value="5026">Costa Rica</option>
<option value="52">Cote D'Ivoire</option>
<option value="5027">Croatia</option>
<option value="5028">Cyprus</option>
<option value="5108">Czech Republic</option>
<option value="5138">Djibouti</option>
<option value="5139">Dominica</option>
<option value="5140">Dominican Republic</option>
<option value="61">East Timor</option>
<option value="5036">Ecuador</option>
<option value="5030">Egypt</option>
<option value="5141">El Salvador</option>
<option value="5142">Equatorial Guinea</option>
<option value="5143">Eritrea</option>
<option value="5031">Estonia</option>
<option value="5144">Ethiopia</option>
<option value="5145">Falkland Islands (Malvinas)</option>
<option value="5146">Faroe Islands</option>
<option value="5147">Fiji</option>
<option value="5032">Finland</option>
<option value="74">France, Metropolitan</option>
<option value="5148">French Guiana</option>
<option value="5149">French Polynesia</option>
<option value="77">French Southern Territories</option>
<option value="5150">Gabon</option>
<option value="5151">Gambia</option>
<option value="5152">Georgia</option>
<option value="5034">Germany</option>
<option value="5101">Ghana</option>
<option value="5153">Gibraltar</option>
<option value="5035">Greece</option>
<option value="5037">Greenland</option>
<option value="5154">Grenada</option>
<option value="5155">Guadeloupe</option>
<option value="5038">Guam</option>
<option value="5156">Guatemala</option>
<option value="5158">Guinea</option>
<option value="5159">Guinea-bissau</option>
<option value="5160">Guyana</option>
<option value="5161">Haiti</option>
<option value="94">Heard and Mc Donald Islands</option>
<option value="5162">Honduras</option>
<option value="5039">Hong Kong</option>
<option value="5040">Hungary</option>
<option value="5041">Iceland</option>
<option value="5042">India</option>
<option value="5043">Indonesia</option>
<option value="5044">Ireland</option>
<option value="5045">Israel</option>
<option value="5048">Jamaica</option>
<option value="5049">Japan</option>
<option value="5050">Jordan</option>
<option value="5165">Kazakhstan</option>
<option value="5051">Kenya</option>
<option value="5166">Kiribati</option>
<option value="5052">Korea: Republic of</option>
<option value="5053">Kuwait</option>
<option value="5168">Kyrgyzstan</option>
<option value="116">Lao People's Democratic Republic</option>
<option value="5054">Latvia</option>
<option value="5056">Lebanon</option>
<option value="5170">Lesotho</option>
<option value="121">Libyan Arab Jamahiriya</option>
<option value="5173">Liechtenstein</option>
<option value="5055">Lithuania</option>
<option value="5174">Luxembourg</option>
<option value="5175">Macau</option>
<option value="5176">Macedonia: The Former Yugoslav Republic of</option>
<option value="5177">Madagascar</option>
<option value="5178">Malawi</option>
<option value="5057">Malaysia</option>
<option value="5060">Maldives</option>
<option value="5179">Mali</option>
<option value="5058">Malta</option>
<option value="5181">Marshall Islands</option>
<option value="5182">Martinique</option>
<option value="5183">Mauritania</option>
<option value="5184">Mauritius</option>
<option value="5185">Mayotte</option>
<option value="5059">Mexico</option>
<option value="5186">Micronesia: Federated States of</option>
<option value="5188">Monaco</option>
<option value="5189">Mongolia</option>
<option value="5190">Montserrat</option>
<option value="5107">Morocco</option>
<option value="5064">Mozambique</option>
<option value="146">Myanmar</option>
<option value="5065">Namibia</option>
<option value="5191">Nauru</option>
<option value="5066">Nepal</option>
<option value="5061">Netherlands</option>
<option value="5192">Netherlands Antilles</option>
<option value="5193">New Caledonia</option>
<option value="5062">New Zealand</option>
<option value="5194">Nicaragua</option>
<option value="5195">Niger</option>
<option value="5102">Nigeria</option>
<option value="5196">Niue</option>
<option value="5197">Norfolk Island</option>
<option value="5198">Northern Mariana Islands</option>
<option value="5199">Palau</option>
<option value="5069">Panama</option>
<option value="5200">Papua New Guinea</option>
<option value="5070">Paraguay</option>
<option value="5071">Peru</option>
<option value="5072">Philippines</option>
<option value="169">Pitcairn</option>
<option value="5073">Poland</option>
<option value="5074">Portugal</option>
<option value="5075">Puerto Rico</option>
<option value="5076">Qatar</option>
<option value="5201">Reunion</option>
<option value="5077">Romania</option>
<option value="5202">Rwanda</option>
<option value="5204">Saint Kitts and Nevis</option>
<option value="5079">Saint Lucia</option>
<option value="5206">Saint Vincent and the Grenadines</option>
<option value="5207">Samoa</option>
<option value="5208">San Marino</option>
<option value="5209">Sao Tome and Principe</option>
<option value="5080">Saudi Arabia</option>
<option value="5210">Senegal</option>
<option value="5211">Seychelles</option>
<option value="5212">Sierra Leone</option>
<option value="5081">Singapore</option>
<option value="5105">Slovakia (Slovak Republic)</option>
<option value="5082">Slovenia</option>
<option value="5213">Solomon Islands</option>
<option value="5083">South Africa</option>
<option value="194">South Georgia and the South Sandwich Islands</option>
<option value="5084">Spain</option>
<option value="5085">Sri Lanka</option>
<option value="197">St. Helena</option>
<option value="198">St. Pierre and Miquelon</option>
<option value="200">Suriname</option>
<option value="5216">Svalbard and Jan Mayen Islands</option>
<option value="5217">Swaziland</option>
<option value="5088">Switzerland</option>
<option value="5089">Taiwan</option>
<option value="5220">Tajikistan</option>
<option value="5106">Tanzania: United Republic of</option>
<option value="5090">Thailand</option>
<option value="5221">Togo</option>
<option value="5222">Tokelau</option>
<option value="5223">Tonga</option>
<option value="5091">Trinidad and Tobago</option>
<option value="5224">Tunisia</option>
<option value="5092">Turkey</option>
<option value="5225">Turkmenistan</option>
<option value="5226">Turks and Caicos Islands</option>
<option value="5227">Tuvalu</option>
<option value="5228">Uganda</option>
<option value="5111">United Arab Emirates</option>
<option value="224">United States Minor Outlying Islands</option>
<option value="5095">Uruguay</option>
<option value="5229">Uzbekistan</option>
<option value="5230">Vanuatu</option>
<option value="5231">Vatican City State (Holy See)</option>
<option value="5097">Viet Nam</option>
<option value="231">Virgin Islands (British)</option>
<option value="5232">Virgin Islands (U.S.)</option>
<option value="5233">Wallis and Futuna Islands</option>
<option value="234">Western Sahara</option>
<option value="237">Zaire</option>
<option value="5098">Zambia</option>
</optgroup>
</select><button type="button" class="btn dropdown-toggle btn-default bs-placeholder" data-toggle="dropdown" role="button" data-id="membership_purchase_billing_BillingAddress_country" title="Select Country">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">Select Country</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
</div>
</div>
<div class="col-12 col-xs-12">
<div class="form-group"><input type="tel" id="membership_purchase_billing_BillingAddress_phone" name="membership_purchase[billing][BillingAddress][phone]" placeholder="Phone Number" class="form-control"></div>
</div>
</div>
</fieldset>
<div class="col-12 col-xs-12 text-center">
<img class="ccIcon" height="35" alt="" src="/images/mastercard.jpg" width="60">
<img class="ccIcon" alt="" src="/images/visa.png?v=799c4f3" width="60">
<img class="ccIcon" height="35" alt="" src="/images/amex.jpg" width="60">
<img class="ccIcon" height="35" alt="" src="/images/discover.jpg" width="60">
</div>
</div>
<div class="billing-section">
<fieldset class="form-group billing-card-wrapper">
<label class="col-form-label">Credit or Debit Card</label>
<div class="row">
<div class="col-6 col-xs-6">
<div class="form-group"><input type="text" id="membership_purchase_billing_creditCard_firstName" name="membership_purchase[billing][creditCard][firstName]" placeholder="First Name" class="form-control"></div>
</div>
<div class="col-6 col-xs-6">
<div class="form-group"><input type="text" id="membership_purchase_billing_creditCard_lastName" name="membership_purchase[billing][creditCard][lastName]" placeholder="Last Name" class="form-control"></div>
</div>
<div class="col-12 col-xs-12">
<input type="hidden" id="membership_purchase_billing_creditCard_new" name="membership_purchase[billing][creditCard][new]" value="1">
</div>
<div class="col-12 col-xs-12">
<div class="ccNewCardRow" style="">
<div class="form-group"><input type="text" id="membership_purchase_billing_creditCard_number" name="membership_purchase[billing][creditCard][number]" placeholder="Card #" class="form-control"></div>
</div>
</div>
<div class="col-4 col-xs-4">
<div class="form-group">
<div class="dropdown bootstrap-select form-control bs3"><select id="membership_purchase_billing_creditCard_month" name="membership_purchase[billing][creditCard][month]" class="form-control" tabindex="-98">
<option value="1">January</option>
<option value="2">February</option>
<option value="3">March</option>
<option value="4">April</option>
<option value="5">May</option>
<option value="6">June</option>
<option value="7">July</option>
<option value="8">August</option>
<option value="9">September</option>
<option value="10">October</option>
<option value="11">November</option>
<option value="12">December</option>
</select><button type="button" class="btn dropdown-toggle btn-default" data-toggle="dropdown" role="button" data-id="membership_purchase_billing_creditCard_month" title="January">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">January</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
</div>
</div>
<div class="col-4 col-xs-4">
<div class="form-group">
<div class="dropdown bootstrap-select form-control bs3"><select id="membership_purchase_billing_creditCard_year" name="membership_purchase[billing][creditCard][year]" class="form-control" tabindex="-98">
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
<option value="2034">2034</option>
<option value="2035">2035</option>
<option value="2036">2036</option>
<option value="2037">2037</option>
<option value="2038">2038</option>
<option value="2039">2039</option>
<option value="2040">2040</option>
<option value="2041">2041</option>
<option value="2042">2042</option>
</select><button type="button" class="btn dropdown-toggle btn-default" data-toggle="dropdown" role="button" data-id="membership_purchase_billing_creditCard_year" title="2022">
<div class="filter-option">
<div class="filter-option-inner">
<div class="filter-option-inner-inner">2022</div>
</div>
</div><span class="bs-caret"><span class="caret"></span></span>
</button>
<div class="dropdown-menu open" role="combobox">
<div class="inner open" role="listbox" aria-expanded="false" tabindex="-1">
<ul class="dropdown-menu inner "></ul>
</div>
</div>
</div>
</div>
</div>
<div class="col-4 col-xs-4">
<div class="form-group"><input type="text" id="membership_purchase_billing_creditCard_code" name="membership_purchase[billing][creditCard][code]" placeholder="CCV" class="form-control"></div>
</div>
</div>
</fieldset>
</div>
</div>
<input type="hidden" id="membership_purchase_billing_paymentType" name="membership_purchase[billing][paymentType]" value="creditCard">
</fieldset>
<div class="billing-footer">
<div class="badge-wrapper">
<img class="ssl-badge" src="//dream-singles-media.s3.amazonaws.com/images/badges/badge-ssl.jpg" alt="ssl secure">
<img src="//dream-singles-media.s3.amazonaws.com/images/badges/badge-mcafee.jpg" alt="mcafee secure">
<img src="//dream-singles-media.s3.amazonaws.com/images/badges/badge-pci.jpg" alt="pci dss certified">
<!-- badges -->
</div>
<div class="pay"> you pay<b>: $0</b>
</div>
<div class="form-group form-section">
<label class="text-left form-control-responsive agree-to-silver pt5" for="membership_purchase_agreeToSilver">
<div class="form-check"> <input type="checkbox" id="membership_purchase_agreeToSilver" name="membership_purchase[agreeToSilver]" required="required" class="form-check-input" value="1">
<label class="form-check-label required" for="membership_purchase_agreeToSilver"></label>
</div> I understand that if I do not cancel my Risk-Free 3-day trial during the first 3 days, I will be billed $9.99 per month.<br>
<br> Your credit card will not be charged until after the Free Trial period has expired. The Free Trial amount will be a hold and will be released if cancelled within 3 days.
</label>
</div>
<div>
<button class="btn btn-pill btn-green btn-submit join-now">find my match now</button>
<!-- button -->
</div>
<!--footer-->
</div>
<input type="hidden" id="membership_purchase_plan" name="membership_purchase[plan]" value="2"> <input type="hidden" name="membership_purchase[bbx]" id="ioBlackBox">
<input type="hidden" id="membership_purchase__token" name="membership_purchase[_token]" value="AJnUBSRo-MxAgvMy6WgyugkuvdCxAhx14vrOgWl5AvY">
</form>Text Content
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