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mc78m9n2j8v0ylqf2-1ymhlncsq4.pub.sfmc-content.com Open in urlscan Pro
136.147.129.3  Public Scan

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URL: https://mc78m9n2j8v0ylqf2-1ymhlncsq4.pub.sfmc-content.com/em0ju0tgovw?qs=60e1ba9dfde3652a12b885a4edfec940ee9838d052e4200f7a4bf009193e33a3f00212eaca59f415
Submission: On May 19 via api from BE — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://mc78m9n2j8v0ylqf2-1ymhlncsq4.pub.sfmc-content.com/em0ju0tgovw?qs=60e1ba9dfde3652a12b885a4edfec940ee9838d052e4200f7a4bf009193e33a3f00212eaca59f415

<form action="https://mc78m9n2j8v0ylqf2-1ymhlncsq4.pub.sfmc-content.com/em0ju0tgovw?qs=60e1ba9dfde3652a12b885a4edfec940ee9838d052e4200f7a4bf009193e33a3f00212eaca59f415" method="POST" onsubmit="return validate()">
  <div>
    <div>
      <b>EMAIL</b>
    </div>
    <div>
      <input type="text" maxlength="254" name="abi_email" id="abi_email" value="dave.ver.eecken@telenet.be" size="50"><br>
      <br>
    </div>
    <div>
      <b>PRENOM</b>
    </div>
    <div>
      <input type="text" maxlength="255" name="abi_first_name" id="abi_first_name" value="Dave" size="50"><br>
      <br>
    </div>
    <div>
      <b>NOM</b>
    </div>
    <div>
      <input type="text" maxlength="255" name="abi_name" id="abi_name" value="" size="50"><br>
      <br>
    </div>
    <div class="webkit-wrap" style="height: 100%;">
      <table width="100%" height="100%" border="0" cellpadding="0" cellspacing="0" class="dashedBorder" style="width: 100%; height: 100%;" bgcolor="">
        <tbody>
          <tr>
            <td style="font-family: Arial; font-size: 13px;">
              <div>
                <b>DATE D'ANNIVERSAIRE</b>
              </div>
              <div>
                <input type="text" maxlength="2" name="Day" id="Day" value="" size="4">&nbsp;&nbsp; <input type="text" maxlength="2" name="Month" id="Month" value="" size="4">&nbsp;&nbsp; <input type="text" maxlength="4" name="Year" id="Year"
                  value="" size="4">
              </div>
            </td>
            <td style="font-family: Arial; font-size: 13px;">
              <div>
                <b>SEXE</b>
                <div>
                  <select name="abi_gender" id="abi_gender">
                    <option value="" selected="selected">--Select--</option>
                    <option value="M">Male</option>
                    <option value="F">Female</option>
                  </select>
                </div>
              </div>
            </td>
          </tr>
        </tbody>
      </table>
    </div>
    <br>
    <div>
      <b>RUE</b>
    </div>
    <div>
      <input type="text" maxlength="255" name="abi_street" id="abi_street" value="" size="50">&nbsp;<br>
    </div>
    <br>
    <div class="webkit-wrap" style="height: 100%;">
      <table width="100%" height="100%" border="0" cellpadding="0" cellspacing="0" class="dashedBorder" style="width: 100%; height: 100%;" bgcolor="">
        <tbody>
          <tr>
            <td style="font-family: Arial; font-size: 13px;">
              <div>
                <b>COMMUNE</b>
                <br>
                <input type="text" maxlength="255" name="abi_city" id="abi_city" value="" size="30">
              </div>
            </td>
            <td style="font-family: Arial; font-size: 13px;">
              <div>
                <b>CODE POSTAL</b>
                <br>
                <input type="text" maxlength="" name="abi_zipcode" id="abi_zipcode" value="" size="10"><br>
              </div>
            </td>
          </tr>
        </tbody>
      </table>
    </div>
    <br>
    <div>
      <b>TELEPHONE</b>
    </div>
    <div>
      <input type="text" maxlength="50" name="abi_phone" id="abi_phone" value="" size="50"><br>
    </div>
    <div>
      <br>
      <br>
      <input type="submit" value="Submit">
      <!-- AMP Processing Placeholder DO NOT REMOVE -->
    </div>
    <input type="hidden" name="sfmc_id" id="sfmc_id" value="dave.ver.eecken@telenet.be">
    <!--
    <input type="hidden" name="__successPage" id="__successPage" value="https://mc78m9n2j8v0ylqf2-1ymhlncsq4.pub.sfmc-content.com/em0ju0tgovw?qs=60e1ba9dfde3652a12b885a4edfec940ee9838d052e4200f7a4bf009193e33a3f00212eaca59f415">
    <input type="hidden" name="__errorPage" id="__errorPage" value="https://mc78m9n2j8v0ylqf2-1ymhlncsq4.pub.sfmc-content.com/em0ju0tgovw?qs=60e1ba9dfde3652a12b885a4edfec940ee9838d052e4200f7a4bf009193e33a3f00212eaca59f415">
    <input type="hidden" name="__contextName" id="__contextName" value="FormPost">
    -->
    <input type="hidden" name="__executionContext" id="__executionContext" value="Post">
    <input type="hidden" name="abi_last_update" id="abi_last_update" value="5/19/2022 9:23:14 AM">
    <input type="hidden" name="abi_last_update_by" id="abi_last_update_by" value="Dave ">
  </div>
</form>

Text Content

Profile Center





EMAIL



PRENOM



NOM



DATE D'ANNIVERSAIRE
     
SEXE
--Select-- Male Female


RUE
 


COMMUNE

CODE POSTAL




TELEPHONE