forms.westock.io Open in urlscan Pro
3.16.193.42  Public Scan

Form analysis
1 forms found in the DOM

Name: requestForm — POST submitForm

<form name="requestForm" method="post" action="submitForm" class="form-body-container" onsubmit="return validate()">
  <div class="form-group">
    <label class="form-title" for="emailField">Enter your email</label>
    <input type="email" name="email" class="form-control" id="emailField" aria-describedby="emailHelp" placeholder="example@example.com" maxlength="50" required="">
  </div>
  <div class="form-group">
    <label class="form-title" for="InputZip">Zip/postal code</label>
    <input type="text" name="zip" class="form-control" id="InputZip" aria-describedby="zipHelp" placeholder="00000" required="">
  </div>
  <div class="form-group">
    <label class="form-title" for="InputStore">Preferred store</label>
    <input id="InputStore" class="form-control typeahead tt-query pac-target-input" spellcheck="false" autocomplete="off" name="store" type="text" placeholder="Enter Location" onfocus="return updateOptions();" required="">
  </div>
  <div class="form-group">
    <label class="form-title" for="InputProduct">Products</label>
    <select id="InputProduct" width="100%" class="chosen form-control form-select" readonly="readonly" spellcheck="false" type="text" name="product" data-placeholder="Select products" multiple="" style="display: none;">
      <option class="form-option" value="5853">Birthday Cake Hemp Bar</option>
      <option class="form-option" value="5850">Brownie Chip Hemp Bar</option>
      <option class="form-option" value="5849">Cookie Dough Hemp Bar</option>
      <option class="form-option" value="5861">Hemp Hearts </option>
      <option class="form-option" value="5864">Hemp90 Protein Supplement</option>
      <option class="form-option" value="5863">Hemp90 Pro+ CBD Protein Supplement</option>
      <option class="form-option" value="5866">Lemon Hemp Bar</option>
    </select>
    <div class="chosen-container chosen-container-multi" title="" id="InputProduct_chosen" style="width: 100%;">
      <ul class="chosen-choices" style="border: none; box-shadow: none; font-size: 21px; background: right center no-repeat transparent; font-family: Raleway, sans-serif;">
        <li class="search-field">
          <input class="chosen-search-input default" type="text" autocomplete="off" value="Select products" style="width: 100%;">
        </li>
      </ul>
      <div class="chosen-drop">
        <ul class="chosen-results"></ul>
      </div><svg id="chevron" style="position: absolute; bottom: 10px; right: 0px;" width="16px" height="10px" viewBox="0 0 35 20">
        <g id="Group" stroke="#384457" stroke-width="5" stroke-linecap="round" fill="none" fill-rule="evenodd">
          <path d="M2.5,2.5 L17.5,17.5" id="Line"></path>
          <path d="M17.5,17.5 L32.5,2.5" id="Line-2"></path>
        </g>
      </svg>
    </div>
    <button type="button" id="selectAllProduct" class="submit-button" onclick="selectAllProducts()">SELECT ALL</button>
  </div>
  <input type="hidden" id="placeIDField" name="placeID">
  <input type="hidden" id="brandIDField" name="brandID" value="1155">
  <input type="hidden" id="storeNameField" name="storeName">
  <input type="hidden" id="storeStreetNumberField" name="storeStreetNumber">
  <input type="hidden" id="storeStreetField" name="storeStreet">
  <input type="hidden" id="storeCityField" name="storeCity">
  <input type="hidden" id="storeStateField" name="storeState">
  <input type="hidden" id="storeCountryField" name="storeCountry">
  <input type="hidden" id="storeZipField" name="storeZip">
  <input type="hidden" id="storeLatitudeField" name="storeLatitude">
  <input type="hidden" id="storeLongitudeField" name="storeLongitude">
  <input type="hidden" id="keywordField" name="keyword" value="null">
  <input type="hidden" id="sourceField" name="source" value="email">
  <input type="hidden" id="mediumField" name="medium" value="email">
  <input type="hidden" id="promoField" name="promo" value="null">
  <input type="hidden" id="testModeField" name="testMode" value="null">
  <div id="submit-request-container" class="submit-container">
    <button class="submit-button" type="submit">MAKE A REQUEST</button>
  </div>
  <br>
  <br> Have any comments or concerns? <br>
  <a href="1155/form/2" class="request-button" target="_blank">SHARE FEEDBACK</a>
</form>

Text Content

REQUEST EVO HEMP LOCALLY

Where do you want to see Evo Hemp? We’ll work to get on the shelf.

Submit the form below to receive a promo code!

Enter your email
Zip/postal code
Preferred store
Products Birthday Cake Hemp BarBrownie Chip Hemp BarCookie Dough Hemp BarHemp
Hearts Hemp90 Protein SupplementHemp90 Pro+ CBD Protein SupplementLemon Hemp Bar
 * 


SELECT ALL
MAKE A REQUEST


Have any comments or concerns?
SHARE FEEDBACK
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