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fs28.formsite.com Open in urlscan Pro
52.5.168.84  Public Scan

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Submitted URL: https://cas5-0-urlprotect.trendmicro.com/wis/clicktime/v1/query?url=https%3a%2f%2ffs28.formsite.com%2f8JjJG6%2fform11%2ffill%3f3%3dChanno...
Effective URL: https://fs28.formsite.com/8JjJG6/form11/fill?3=Channon%20Walker&4=I-062223-434788
Submission: On June 23 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://fs28.formsite.com/res/submit

<form method="post" id="FSForm" action="https://fs28.formsite.com/res/submit" enctype="application/x-www-form-urlencoded" onsubmit="return Vromansys.Form.processSubmit(this);">
  <div style="display:none">
    <input type="hidden" name="GenId" value="tDE1c4TeBaNP3pHq">
    <input type="hidden" name="LocId" value="8JjJG6/form11">
    <input type="hidden" name="EParam" value="AT1kKIiyxDzKHnIjUnQ5b6eLTfEDMMCuFA9mI_bo_cv6LRTb7k8HLu8TZisB57HAvZP9dpQKLgC9Q4edV-QvqBc6VAmcJw56">
    <input type="hidden" name="ElapsedTime" id="ElapsedTime" value="0">
    <input type="hidden" name="Referrer" id="Referrer" value="">
    <input type="text" name="subject_line" id="subject_line" autocomplete="off"><label for="subject_line">subject_line</label>
  </div>
  <!-- BEGIN_ITEMS -->
  <div class="form_table">
    <div class="clear"></div>
    <div id="q210" class="q full_width">
      <a class="item_anchor" name="ItemAnchor0"></a>
      <div class="full_width_space" style="text-align:center"><img src="images/EmpInfo_Logo_2.png" alt="" width="200"></div>
    </div>
    <div class="clear"></div>
    <div id="q2" class="q full_width">
      <a class="item_anchor" name="ItemAnchor1"></a>
      <div class="segment_header" style="background:#800000;width:auto;text-align:Left;">
        <h1 style="font-weight:bold;font-size:18px;font-family:'Lucida Sans Unicode','Lucida Grande',sans-serif;padding-bottom:0px;padding-top:0px;">DECLINE - EMPLOYMENT VERIFICATION</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q207" class="q read_only">
      <a class="item_anchor" name="ItemAnchor2"></a>
      <label class="question top_question" for="RESULT_TextField-2"><span style="font-size: 14px; color: #ffffff; background-color: #333333;">Employee's Name</span></label>
      <input type="text" name="RESULT_TextField-2" class="text_field read_only" id="RESULT_TextField-2" size="40" maxlength="255" disabled="" value="Channon Walker">
    </div>
    <div class="clear"></div>
    <div id="q226" class="q required">
      <a class="item_anchor" name="ItemAnchor4"></a>
      <label class="question top_question" for="RESULT_RadioButton-4">Declining reason (please enter below)&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <select id="RESULT_RadioButton-4" name="RESULT_RadioButton-4" class="drop_down">
        <option></option>
        <option value="Radio-0">Terminated</option>
        <option value="Radio-1">Incorrect Employer or Recipient</option>
        <option value="Radio-2">Require employee's partial or full SSN</option>
        <option value="Radio-3">No employee works here by that name</option>
        <option value="Radio-4">Employee declined and/or advised not to respond</option>
        <option value="Radio-5">A signed authorization to release information is required</option>
        <option value="Radio-6">Other</option>
      </select>
    </div>
    <div class="clear"></div>
    <div id="q206" class="q display_hidden">
      <a class="item_anchor" name="ItemAnchor5"></a>
      <label class="question top_question" for="RESULT_TextField-5"><span style="font-size: 16px;">Enter other reason</span></label>
      <input type="text" name="RESULT_TextField-5" class="text_field" id="RESULT_TextField-5" size="25" maxlength="255" value="" disabled="">
    </div>
    <div class="clear"></div>
    <div id="q224" class="q full_width">
      <a class="item_anchor" name="ItemAnchor6"></a>
      <div class="segment_header" style="width:auto;text-align:Left;">
        <h1 style="font-size:18px;font-family:'Lucida Sans Unicode','Lucida Grande',sans-serif;padding-bottom:0px;padding-top:0px;">Your Contact Information</h1>
      </div>
    </div>
    <div class="clear"></div>
    <div id="q228" class="q required">
      <a class="item_anchor" name="ItemAnchor7"></a>
      <span class="question top_question">I Agree&nbsp;<b class="icon_required" style="color:#F00">*</b></span>
      <table class="inline_grid choices">
        <tbody>
          <tr>
            <td><input type="checkbox" name="RESULT_CheckBox-7" class="multiple_choice" id="RESULT_CheckBox-7_0" value="CheckBox-0"><label for="RESULT_CheckBox-7_0">I am authorized by our organization to respond to the verification request.</label>
            </td>
          </tr>
        </tbody>
      </table>
    </div>
    <div id="q213" class="q required">
      <a class="item_anchor" name="ItemAnchor8"></a>
      <label class="question top_question" for="RESULT_TextField-8">Name&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="text" name="RESULT_TextField-8" class="text_field" id="RESULT_TextField-8" size="35" maxlength="255" value="">
    </div>
    <div id="q208" class="q">
      <a class="item_anchor" name="ItemAnchor9"></a>
      <label class="question top_question" for="RESULT_TextField-9">Title</label>
      <input type="text" name="RESULT_TextField-9" class="text_field" id="RESULT_TextField-9" size="30" maxlength="255" value="">
    </div>
    <div class="clear"></div>
    <div id="q10" class="q required">
      <a class="item_anchor" name="ItemAnchor10"></a>
      <label class="question top_question" for="RESULT_TextField-10">Phone# (Work )&nbsp;<b class="icon_required" style="color:#F00">*</b></label>
      <input type="text" name="RESULT_TextField-10" class="text_field" id="RESULT_TextField-10" size="18" maxlength="100" value="">
    </div>
    <div id="q177" class="q">
      <a class="item_anchor" name="ItemAnchor11"></a>
      <label class="question top_question" for="RESULT_TextField-11">Fax#</label>
      <input type="text" name="RESULT_TextField-11" class="text_field" id="RESULT_TextField-11" size="18" maxlength="100" value="">
    </div>
    <div id="q178" class="q">
      <a class="item_anchor" name="ItemAnchor12"></a>
      <label class="question top_question" for="RESULT_TextField-12">Mobile#</label>
      <input type="text" name="RESULT_TextField-12" class="text_field" id="RESULT_TextField-12" size="18" maxlength="100" value="">
    </div>
    <div class="clear"></div>
    <div id="q180" class="q">
      <a class="item_anchor" name="ItemAnchor13"></a>
      <label class="question top_question" for="RESULT_TextField-13">Employer's Email ID</label>
      <input type="email" name="RESULT_TextField-13" class="text_field" id="RESULT_TextField-13" size="45" maxlength="255" value="">
    </div>
    <div class="clear"></div>
  </div>
  <!-- END_ITEMS -->
  <script>
    var itemInstructions = {
      210: "200"
    };
  </script>
  <script>
    var itemRules = {
      206: {
        "criteria": [{
          "item": 226,
          "answer": "6",
          "operator": "=="
        }],
        "action": "show",
        "join": "||"
      }
    };
  </script>
  <div class="outside_container">
    <div class="buttons_reverse"><input type="submit" name="Submit" value="Submit" class="submit_button" id="FSsubmit"></div>
  </div>
  <div class="outside_container"><a href="https://www.formsite.com//?utm_source=formads&amp;utm_medium=securebadge&amp;utm_campaign=formads" target="_top"><img class="svg" src="/images/logos/Secured_by_FormSite.svg" alt="Secured by Formsite"></a>
  </div>
  <div class="outside outside_container">
    <div class="row-fluid footer-container">
      <div class="span3">
        <h3 class="widget-title"><span style="color: #ffffff;">CONTACT</span></h3>
      </div>
    </div>
    <div><span style="color: #ffffff;">www.empinfo.com &nbsp; &nbsp; | &nbsp; &nbsp; &nbsp; <span
          style="background: transparent url('chrome-extension://ildccibmanndgalianjghiompgkcmkli/inc/img/Chrome-38.png') no-repeat right 50%; background-position: 100% 50%; background-size: 12px 12px; padding-right: 15px; cursor: pointer;"
          title="Click-To-Dial (800) 274-9694">(800) 274-9694</span></span></div>
    <div id="footer-bottom"><span style="color: #ffffff;">2017 © EmpInfo Inc. All rights reserved.</span></div>
  </div>
</form>

Text Content

subject_line


DECLINE - EMPLOYMENT VERIFICATION


Employee's Name

Declining reason (please enter below) * Terminated Incorrect Employer or
Recipient Require employee's partial or full SSN No employee works here by that
name Employee declined and/or advised not to respond A signed authorization to
release information is required Other

Enter other reason



YOUR CONTACT INFORMATION


I Agree *

I am authorized by our organization to respond to the verification request.

Name *
Title

Phone# (Work ) *
Fax#
Mobile#

Employer's Email ID





CONTACT

www.empinfo.com     |       (800) 274-9694
2017 © EmpInfo Inc. All rights reserved.