pengaduanamd.com Open in urlscan Pro
2606:4700:3031::6815:34f4  Public Scan

Form analysis
1 forms found in the DOM

POST

<form method="POST" enctype="multipart/form-data">
  <!-- CSRF Token -->
  <input type="hidden" name="csrf_token" value="04bccf2ca239e00606ede97424964e6dc82463f312fbb4ee00bf75b6d16a1fb5">
  <div class="form-row">
    <div class="form-group col-md-6">
      <label for="username"><i class="fas fa-user"></i> Username</label>
      <input type="text" name="username" class="form-control" id="username" required="">
    </div>
    <div class="form-group col-md-6">
      <label for="nomor_whatsapp"><i class="fas fa-phone-alt"></i> Nomor WhatsApp</label>
      <input type="text" name="nomor_whatsapp" class="form-control" id="nomor_whatsapp" required="">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-6">
      <label for="tanggal"><i class="fas fa-calendar-alt"></i> Tanggal</label>
      <input type="date" name="tanggal" class="form-control" id="tanggal" required="">
    </div>
    <div class="form-group col-md-6">
      <label for="situs_bo"><i class="fas fa-globe"></i> Situs BO</label>
      <select name="situs_bo" class="form-control" id="situs_bo" required="">
        <option value="AMDBET">AMDBET</option>
      </select>
    </div>
  </div>
  <div class="form-group">
    <label for="kendala"><i class="fas fa-exclamation-triangle"></i> Kendala</label>
    <textarea name="kendala" class="form-control" id="kendala" rows="3" required=""></textarea>
  </div>
  <div class="form-group">
    <label for="level_permasalahan"><i class="fas fa-tasks"></i> Level Permasalahan</label>
    <select name="level_permasalahan" class="form-control" id="level_permasalahan" required="">
      <option value="Low">Low</option>
      <option value="Medium">Medium</option>
      <option value="High">High</option>
    </select>
  </div>
  <div class="form-group">
    <label for="file"><i class="fas fa-upload"></i> Upload File (Gambar, maksimal 32MB)</label>
    <input type="file" name="file" class="form-control-file" id="file" accept="image/*" required="">
  </div>
  <button type="submit" class="btn btn-primary btn-block">Kirim Pengaduan</button>
</form>

Text Content

FORM PENGADUAN MEMBER

Username
Nomor WhatsApp
Tanggal
Situs BO AMDBET
Kendala
Level Permasalahan Low Medium High
Upload File (Gambar, maksimal 32MB)
Kirim Pengaduan

PENGADUAN BERHASIL DIKIRIM

×
Pengaduan Anda telah berhasil dikirim. Terima kasih atas laporan Anda.
Tutup