portal.verittex.com Open in urlscan Pro
51.254.197.126  Public Scan

Form analysis
1 forms found in the DOM

POST https://portal.verittex.com/register

<form id="email-form" action="https://portal.verittex.com/register" method="post" class="sign-up-form">
  <input type="hidden" name="_token" value="A7RBvvmFw0l6KjEjUL7XKEqwHxMiwn4JAmIfIMve">
  <div class="field-split">
    <div class="spacer _24"></div>
    <div class="spacer _32">
    </div><label class="form-radio-button w-radio">
      <div class="w-form-formradioinput w-form-formradioinput--inputType-custom radio-button w-radio-input"></div>
      <input type="radio" data-name="Radio" id="Personal" name="Radio" value="Personal" required="" style="opacity:0;position:absolute;z-index:-1">
      <span for="Personal" class="paragraph medium w-form-label">Personal</span>
    </label>
    <label class="form-radio-button w-radio">
      <div class="w-form-formradioinput w-form-formradioinput--inputType-custom radio-button w-radio-input"></div>
      <input type="radio" data-name="Radio" id="Business" name="Radio" value="Business" required="" style="opacity:0;position:absolute;z-index:-1">
      <span for="Business" class="paragraph medium w-form-label">Business</span>
    </label>
  </div>
  <div class="spacer _16">
  </div>
  <div class="spacer _16">
  </div>
  <input type="text" class="simple-input no-margin w-input" maxlength="256" name="name" data-name="Name" placeholder="Enter your full name" id="Name">
  <div class="spacer _16">
  </div>
  <input type="email" class="simple-input no-margin w-input" maxlength="256" name="email" data-name="Email" placeholder="Enter your email" id="Email" required="">
  <div class="spacer _16"> </div>
  <input type="tel" class="simple-input no-margin w-input" maxlength="256" name="phone" data-name="Phone Number" placeholder="Enter your phone number" id="Phone-Number" required="">
  <div class="spacer _24">
  </div>
  <input type="text" class="simple-input no-margin w-input" maxlength="256" name="username" data-name="Name" placeholder="Enter your username" id="Name">
  <div class="spacer _16">
  </div>
  <input type="password" class="simple-input no-margin w-input" maxlength="256" name="password" data-name="Name" placeholder="Enter password" id="Name">
  <div class="spacer _16">
  </div>
  <input type="password" class="simple-input no-margin w-input" maxlength="256" name="password_confirmation" placeholder="Confirm password" id="Name">
  <div class="spacer _16">
  </div>
  <input type="submit" value="Apply Now" data-wait="Please wait..." class="button no-margin w-button">
</form>

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