www.booking.immortalgroup.co.id Open in urlscan Pro
180.235.151.11  Public Scan

Form analysis
1 forms found in the DOM

POST https://www.booking.immortalgroup.co.id/ceklogin3/

<form action="https://www.booking.immortalgroup.co.id/ceklogin3/" autocomplete="off" method="post">
  <div class="input-group mb-3">
    <input type="text" class="form-control" name="nama_customer" id="nama_customer" placeholder="Nama Lengkap" required="">
    <div class="input-group-append">
      <div class="input-group-text">
        <span class="fas fa-user"></span>
      </div>
    </div>
  </div>
  <div class="input-group mb-3" style="width:75%;">
    <input type="email" class="form-control" name="email_customer" id="email_customer" placeholder="Email" required="">
    <div class="input-group-append">
      <div class="input-group-text">
        <span class="fas fa-envelope"></span>
      </div>
      <span id="usercheck" class="help-block" style="float:left; padding:4px;"></span>
    </div>
  </div>
  <div class="input-group mb-3" style="width:75%;">
    <input type="text" class="form-control" id="no_whatsapp" name="no_whatsapp" placeholder="No Whatsapp" required="">
    <div class="input-group-append">
      <div class="input-group-text">
        <span class="fas fa-phone"></span>
      </div>
      <span id="wacheck" class="help-block" style="float:left; padding:4px;"></span>
    </div>
  </div>
  <div class="input-group mb-3">
    <input type="password" class="form-control" id="password" name="password" placeholder="Password" required="">
    <div class="input-group-append">
      <div class="input-group-text">
        <span class="fas fa-key"></span>
      </div>
    </div>
  </div>
  <div class="input-group mb-3">
    <textarea name="alamat" class="form-control textisi" id="alamat" placeholder="Isikan Alamat lengkap"></textarea>
  </div>
  <div class="input-group mb-3">
    <img src="https://www.booking.immortalgroup.co.id/captcha.php" alt="gambar">
  </div>
  <div class="input-group mb-3">
    <input type="text" class="form-control" id="captcha" name="captcha" placeholder="Isi Captcha" required="">
    <input type="hidden" class="form-control" id="emsts" name="emsts">
    <input type="hidden" class="form-control" id="wasts" name="wasts">
  </div>
  <!-- /.col -->
  <div class="col-4">
    <button type="submit" id="simpan" class="btn btn-primary btn-block">Register</button>
  </div>
  <!-- /.col -->
</form>

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