surveysailor.com
Open in
urlscan Pro
2a06:98c1:3120::3
Public Scan
Submitted URL: https://djnl.spinfastconnected.com/o/1OMTHUJN/c09ec5be-ed4d-11ee-a7f6-2dde38ae7055/c0c8fe1a-ed4d-11ee-b648-3b15e4dae513
Effective URL: https://surveysailor.com/
Submission: On March 28 via manual from US — Scanned from DE
Effective URL: https://surveysailor.com/
Submission: On March 28 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /flow?uid=4ec929a2-db51-41f4-a278-208c8c750e6f
<form id="formSubmit" action="/flow?uid=4ec929a2-db51-41f4-a278-208c8c750e6f" method="POST" data-effect="" data-effect-duration="">
<div id="f1" class="dynamic-form form-step form1 form1-1">
<div class="row row-spacing" data-row-id="1">
<div id="col-field-first_name" class="col first-name form-field-col" data-col-id="1" data-autohide="false">
<input id="first_name" type="text" name="first_name" class="path-form-field-with-feedback path-dynamic-field required" title="First Name" value="" placeholder="First Name">
<span id="first_name-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
<script>
document.querySelector('#first_name').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#first_name-error-feedback')
var elem = this
evt.detail.setControls(
'eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiJGaXJzdCBOYW1lIn0sInZpc2liaWxpdHkiOnsidHlwZSI6ImhpZGUiLCJhY3Rpb25zIjpbXSwiYXV0b2hpZGUiOmZhbHNlfSwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
evt.detail.assignToState('first_name')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
<div id="col-field-last_name" class="col last-name form-field-col" data-col-id="2" data-autohide="false">
<input id="last_name" type="text" name="last_name" class="path-form-field-with-feedback path-dynamic-field required" title="Last Name" value="" placeholder="Last Name">
<span id="last_name-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
<script>
document.querySelector('#last_name').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#last_name-error-feedback')
var elem = this
evt.detail.setControls(
'eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiJMYXN0IE5hbWUifSwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6ZmFsc2V9LCJ2YWxpZGF0aW9ucyI6eyJhY3Rpb25zIjpbXSwicmVxdWlyZWQiOnRydWV9fQ%3D%3D')
evt.detail.assignToState('last_name')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
</div>
<div class="row row-spacing" data-row-id="2">
<div id="col-field-email" class="col e-mail-required form-field-col" data-col-id="1" data-autohide="false">
<label class="label">E-mail</label>
<input id="email" list="email_domains" type="email" name="email" class="path-form-field-with-feedback path-dynamic-field required" title="Email" data-session-verification="-1" value="" placeholder="E-mail">
<span id="emailmessage" class="invalid-feedback hidden path-form-feedback"></span>
<datalist id="email_domains"></datalist>
<script>
document.querySelector('#email').addEventListener('path-dynamic-field-register', function(evt) {
var domains = ["gmail.com", "yahoo.com", "hotmail.com", "aol.com", "hotmail.co.uk", "hotmail.fr", "msn.com", "yahoo.fr", "wanadoo.fr", "orange.fr", "comcast.net", "yahoo.co.uk", "yahoo.co.in", "live.com", "rediffmail.com", "free.fr",
"gmx.de", "web.de", "yandex.ru", "ymail.com", "libero.it", "outlook.com", "uol.com", "bol.com", "mail.ru", "cox.net", "hotmail.it", "sbcglobal.net", "sfr.fr", "live.fr", "verizon.net", "live.co.uk", "googlemail.com", "yahoo.es",
"ig.com", "live.nl", "bigpond.com", "terra.com", "yahoo.it", "neuf.fr", "yahoo.de", "alice.it", "rocketmail.com", "att.net", "laposte.net", "facebook.com", "bellsouth.net", "yahoo.in", "hotmail.es", "charter.net", "yahoo.ca",
"yahoo.com.au", "rambler.ru", "hotmail.de", "tiscali.it", "shaw.ca", "yahoo.co.jp", "sky.com"
]
var feedbackElem = document.querySelector('#emailmessage')
var emailDomains = document.querySelector('#email_domains')
var elem = this
evt.detail.overrideOnChangeListener(function() {
elem.addEventListener('input', evt.detail.listener(function(evt, setValue) {
var value = evt.target.value
setValue(value)
var split = value.split('@')
var username = split[0]
var domain = split[1]
var regex = domain && new RegExp('@' + domain)
emailDomains.innerHTML = ''
domains.forEach(function(domain) {
if (regex && regex.test('@' + domain) && username + '@' + domain !== value) {
var option = emailDomains.appendChild(document.createElement('option'))
option.setAttribute('value', username + '@' + domain)
}
})
}))
})
evt.detail.setControls(
'eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiJFLW1haWwifSwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6ZmFsc2V9LCJ2YWxpZGF0aW9ucyI6eyJhY3Rpb25zIjpbXSwicmVxdWlyZWQiOnRydWV9fQ%3D%3D')
evt.detail.assignToState('test')
evt.detail.assignToState('email', evt.detail.effects.test)
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
<div id="col-field-phone" class="col phone form-field-col" data-col-id="2" data-autohide="false">
<label class="label">Phone</label>
<input id="phone" type="tel" name="phone" title="Phone" data-session-verification="-1" value="" class="path-dynamic-field path-form-field-with-feedback required" pattern="[0-9]*" inputmode="numeric" placeholder="Phone"
autocomplete="tel-national">
<span id="phone-error-feedback" class="invalid-feedback hidden path-form-feedback invalid-phone"></span>
<script>
document.querySelector('#phone').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#phone-error-feedback')
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiJQaG9uZSJ9LCJ2aXNpYmlsaXR5Ijp7InR5cGUiOiJoaWRlIiwiYWN0aW9ucyI6W10sImF1dG9oaWRlIjpmYWxzZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.assignToState('phone')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillInputPhone(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
</div>
<div class="row row-spacing" data-row-id="3">
<div id="col-field-address1" class="col address-1 form-field-col" data-col-id="1" data-autohide="true">
<input id="addressform" type="text" name="addressform" title="Address" value="" class="path-dynamic-field path-form-field-with-feedback required" placeholder="Address 1" autocomplete="address-line1">
<span id="address1-error-feedback" class="invalid-feedback hidden path-form-feedback invalid-postal"></span>
<input id="address1" type="hidden" name="address1" title="Address" value="">
<script>
document.querySelector('#addressform').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#address1-error-feedback')
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiJBZGRyZXNzIDEifSwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6dHJ1ZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.assignToState('address1')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
<div id="col-field-address2" class="col address-2 form-field-col" data-col-id="2" data-autohide="true">
<input id="address2" type="text" name="address2" value="" class="path-form-field-with-feedback path-dynamic-field " placeholder="Apt / Suite" autocomplete="address-line2">
<span id="address2-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
<script>
document.querySelector('#address2').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#address2-error-feedback')
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiJBcHQgLyBTdWl0ZSJ9LCJ2aXNpYmlsaXR5Ijp7InR5cGUiOiJoaWRlIiwiYWN0aW9ucyI6W10sImF1dG9oaWRlIjp0cnVlfSwidmFsaWRhdGlvbnMiOm51bGx9')
evt.detail.assignToState('address2')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
</div>
<div class="row row-spacing" data-row-id="4">
<div id="col-field-city" class="col city form-field-col" data-col-id="1" data-autohide="true">
<label class="label">City</label>
<input id="city" type="text" name="city" title="City" value="" class="path-form-field-with-feedback path-dynamic-field required" autocomplete="address-level2">
<span id="city-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
<script>
document.querySelector('#city').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#city-error-feedback')
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6dHJ1ZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.assignToState('city')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
<div id="col-field-state" class="col state form-field-col" data-col-id="2" data-autohide="true">
<label class="label">State</label>
<select id="state" name="state" title="State" class="path-form-field-with-feedback path-dynamic-field required" value="" datavalue="">
<option value=""> Select State </option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
<span id="state-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
<script>
document.querySelector('#state').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#state-error-feedback')
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6dHJ1ZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.assignToState('state')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
populate_options: renders.fillSelectOptions(elem, `
Select State
`),
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
<div id="col-field-zip" class="col zip-code form-field-col" data-col-id="3" data-autohide="true">
<label class="label">Zip</label>
<input id="zip" type="text" name="zip" title="Zipcode" maxlength="5" data-session-verification="-1" value="" class="path-form-field-with-feedback required path-dynamic-field" pattern="[0-9]*" inputmode="numeric" placeholder="Zip Code"
autocomplete="postal-code">
<span id="zip-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
<script>
document.querySelector('#zip').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#zip-error-feedback')
var elem = this
evt.detail.setControls(
'eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiJaaXAgQ29kZSJ9LCJ2aXNpYmlsaXR5Ijp7InR5cGUiOiJoaWRlIiwiYWN0aW9ucyI6W10sImF1dG9oaWRlIjp0cnVlfSwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
evt.detail.assignToState('zip')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
prepopulate_with: renders.fillZip(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
$(elem).change()
})
</script>
</div>
</div>
<div class="row row-spacing" data-row-id="5">
<div id="col-field-dob" class="col date-of-birth form-field-col" data-col-id="1" data-autohide="true">
<label class="label">Date of Birth</label>
<div class="row path-form-field-with-feedback-control">
<div class="col">
<select id="dob_month" name="dob_month" title="Dob Month" autocomplete="bday-month" class="path-dynamic-field required">
<option value=""> Month </option>
<option value="01">Jan</option>
<option value="02">Feb</option>
<option value="03">Mar</option>
<option value="04">Apr</option>
<option value="05">May</option>
<option value="06">Jun</option>
<option value="07">Jul</option>
<option value="08">Aug</option>
<option value="09">Sep</option>
<option value="10">Oct</option>
<option value="11">Nov</option>
<option value="12">Dec</option>
</select>
</div>
<div class="col">
<select id="dob_day" name="dob_day" title="Dob Day" autocomplete="bday-day" class="path-dynamic-field required">
<option value=""> Day </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
</div>
<div class="col">
<select id="dob_year" name="dob_year" title="Dob Year" autocomplete="bday-year" class="path-dynamic-field required">
<option value=""> Year </option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980" selected="">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
</select>
</div>
</div>
<span id="dobmessage" class="invalid-feedback hidden path-form-feedback"></span>
<script>
var feedbackElem = document.querySelector('#dobmessage')
document.querySelector('#dob_day').addEventListener('path-dynamic-field-register', function(evt) {
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6dHJ1ZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.assignToState('dob_day', evt.detail.effects.age)
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
populate_options: renders.fillSelectOptions(elem, `
Day
`),
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
document.querySelector('#dob_year').addEventListener('path-dynamic-field-register', function(evt) {
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6dHJ1ZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.assignToState('age')
evt.detail.assignToState('dob_year', evt.detail.effects.age)
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
populate_options: renders.fillSelectOptions(elem, `
Year
`),
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
document.querySelector('#dob_month').addEventListener('path-dynamic-field-register', function(evt) {
var elem = this
evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6dHJ1ZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.assignToState('dob_month', evt.detail.effects.age)
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
populate_options: renders.fillSelectOptions(elem, `
Month
`),
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
<div id="col-field-gender" class="col gender form-field-col" data-col-id="2" data-autohide="true">
<label class="label">Gender</label>
<select id="gender" data-value="" data-type="gender" name="gender" title="Gender" class="path-form-field-with-feedback path-dynamic-field required">
<option value=""> Select Gender </option>
<option value="M">Male</option>
<option value="F">Female</option>
</select>
<span id="gender-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
<script>
document.querySelector('#gender[data-type=gender]').addEventListener('path-dynamic-field-register', function(evt) {
var feedbackElem = document.querySelector('#gender-error-feedback')
var elem = this
evt.detail.assignToState('gender')
evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6eyJ0eXBlIjoiaGlkZSIsImFjdGlvbnMiOltdLCJhdXRvaGlkZSI6dHJ1ZX0sInZhbGlkYXRpb25zIjp7ImFjdGlvbnMiOltdLCJyZXF1aXJlZCI6dHJ1ZX19')
evt.detail.render(function(renders) {
return {
hide: renders.hideParentFieldForm(elem),
show: renders.hideParentFieldForm(elem, false),
populate: {
populate_options: renders.fillSelectOptions(elem, `
Select Gender
`),
prepopulate_with: renders.fillInput(elem)
},
validation: renders.fillFeedbackMessage(feedbackElem)
}
})
})
</script>
</div>
</div>
<div class="row row-spacing" data-row-id="6">
<div id="col-field-registration_consent" class="col registration-consent form-field-col" data-col-id="1" data-autohide="false">
<div class="terms termschk">
<input type="checkbox" class="chkbox path-dynamic-field" id="chkterms" name="chkterms" checked="" value="on">
<label class="term-label terms-label--checkbox" for="chkterms"> By clicking "Continue" below, I agree that I am a US resident over the age of 18 and agree to the Terms of Use and Privacy Policy, and site visit recordation by TrustedForm and
Jornaya, and I agree to receiving relevant Survey Sailor and The Accident Office emails. </label>
<script>
document.querySelector('#chkterms').addEventListener('path-dynamic-field-register', function(evt) {
var elem = this
evt.detail.assignToState('registrationConsent', function(value) {
elem.dispatchEvent(new CustomEvent('path-event-registration-consent-changed'))
return elem.checked
})
})
</script>
</div>
</div>
</div>
<div class="row row-spacing" data-row-id="7">
<div id="col-field-tcpa_consent" class="col tcpa-consent form-field-col" data-col-id="1" data-autohide="">
<div class="tcpa-terms">
<input type="checkbox" class="chkbox path-dynamic-field " "="" id=" leadid_tcpa_disclosure" name="chktcpa" checked="" value="on">
<label class="term-label" for="leadid_tcpa_disclosure"> By checking the box I consent to receive phone sales calls or SMS text messages - Msg and data rates may apply - from Survey Sailor and The Accident Office on the landline or mobile
number I provided even if I am on the federal or state do not call registry. I understand these calls and SMS text messages may be generated using an autodialer and may contain pre-recorded messages and that consenting is not required to
participate in the offers promoted. I understand that I may revoke consent at any time. Text STOP to opt out and HELP to receive help. </label>
<script>
document.querySelector('#leadid_tcpa_disclosure').addEventListener('path-dynamic-field-register', function(evt) {
var elem = this
evt.detail.assignToState('tcpaConsent', function(value) {
return elem.checked
})
evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjpmYWxzZX19')
evt.detail.render(function(renders) {
return {
validation: renders.overrideTcpaConsentAlertText
}
})
})
</script>
</div>
</div>
</div>
<div class="row row-spacing" data-row-id="8">
<div id="col-field-twyne_registration" class="col twyne-registration form-field-col" data-col-id="1" data-autohide="">
<div class="form-row">
<div id="sploffrs" class="form-col x-12 sploffrs">
<script type="text/javascript" src="https://htm.api.twyne.io/assets/form.js"></script>
<script type="text/javascript" id="twyne-embed" class="twyne-embed">
(function(global) {
function twyne_load() {
var data = {};
data.pid = '1';
data.sid = '71';
data.first = '';
data.last = '';
data.email = '';
data.address1 = '';
data.address2 = '';
data.city = '';
data.gender = '';
data.state = '';
data.zip = '';
data.phone = '';
data.dob = '//';
data.istest = 'n';
data.externalgroup = 'J0JoI-BfL0Kp6-wu-Cs_';
data.country = 'US';
data.subid1 = '3241-93374_25bd4467839';
data.subid2 = '';
data.loading = {
enabled: false
};
data.embedUrlOverride = 'https://htm.api.twyne.io/';
data.formRegistration = {
binders: {
'first': 'first_name',
'last': 'last_name',
'email': 'email',
'address1': 'addressform',
'address2': 'address2',
'city': 'city',
'gender': 'gender',
'state': 'state',
'zip': 'zip',
'phone': 'phone'
},
customFields: ['dob'],
optionalFields: ['address2'],
triggerType: 'fields',
rules: ["email"]
}
global.twyne.initEmbed(data);
}
document.addEventListener("DOMContentLoaded", twyne_load);
})(this);
</script>
</div>
</div>
</div>
</div>
<div class="row row-spacing" data-row-id="9">
<div id="col-field-submit" class="col custom-submit-button form-field-col-ignored" data-col-id="1" data-autohide="">
<button class="btn form-button submitbutton form-submit-button" type="button" id="submitbutton">
<span>CONTINUE</span>
<i class="fa fa-spinner fa-spin"></i>
</button>
</div>
</div>
</div>
<div class="form-row">
<div class="x-12 col-mobile center">
</div>
</div>
<div class="hidden">
<input type="hidden" id="numForms" name="numForms" value="1">
<input type="hidden" id="tcpaStep" name="tcpaStep" value="-1">
<input type="hidden" id="registrationStep" name="registrationStep" value="-1">
<input type="hidden" id="currentForm" name="currentForm" value="1">
<input type="hidden" id="uid" name="uid" value="4ec929a2-db51-41f4-a278-208c8c750e6f">
<input type="hidden" id="tcpaconsent" name="tcpaconsent" value="">
<input type="hidden" id="consent" name="consent" value="">
<input type="hidden" id="pathAid" name="pathAid" value="9655">
<input type="hidden" id="pathPid" name="pathPid" value="3241">
<input type="hidden" id="pathSid1" name="pathSid1" value="93374_25bd4467839">
<input type="hidden" id="registrationCheck" name="registrationCheck" value="false">
<input type="hidden" id="addressCheck" name="addressCheck" value="false">
<input type="hidden" id="fraudCheck" name="fraudCheck" value="true">
<input type="hidden" id="emailValid" name="emailValid" value="false">
<input type="hidden" id="addressValid" name="addressValid" value="false">
<input type="hidden" name="origin" value="submit">
<input type="hidden" id="haddress1" value="">
<input type="hidden" id="haddress2" value="">
<input type="hidden" id="hcity" value="">
<input type="hidden" id="hstate" value="">
<input type="hidden" id="hzipcode" value="">
<div id="pixel"></div>
<script type="text/javascript">
(function() {
var field = 'xxTrustedFormCertUrl';
var provideReferrer = false;
var invertFieldSensitivity = false;
var tf = document.createElement('script');
tf.type = 'text/javascript';
tf.async = true;
tf.src = 'http' + ('https:' == document.location.protocol ? 's' : '') + '://api.trustedform.com/trustedform.js?provide_referrer=' + escape(provideReferrer) + '&field=' + escape(field) + '&l=' + new Date().getTime() + Math.random() +
'&invert_field_sensitivity=' + invertFieldSensitivity;
var s = document.getElementsByTagName('script')[0];
s.parentNode.insertBefore(tf, s);
})();
</script>
<noscript>
<img src="http://api.trustedform.com/ns.gif">
</noscript>
<input id="leadid_token" name="universal_leadid" type="hidden" value="A0816C9C-542B-CE01-A9BD-134E349AE19F">
</div>
<input type="hidden" name="xxTrustedFormToken" id="xxTrustedFormToken_0" value="https://cert.trustedform.com/b2e1f3016515d9985be9856d0191fef0246d4bc9"><input type="hidden" name="xxTrustedFormCertUrl" id="xxTrustedFormCertUrl_0"
value="https://cert.trustedform.com/b2e1f3016515d9985be9856d0191fef0246d4bc9"><input type="hidden" name="xxTrustedFormPingUrl" id="xxTrustedFormPingUrl_0"
value="https://ping.trustedform.com/0.piVrYsUZOng9imYl_wejAaeC15xvTNU_bOZO7wvGD3cHoaVsEsK2Cq8QH05ZRyO4bjPG7lMb.KPEEwekJBShBC4OebuE6tg.ufGz7EdRNK_7pbFCQi5CaA">
</form>Text Content
E-mail Phone City State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Date of Birth Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 20062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924 Gender Select Gender Male Female By clicking "Continue" below, I agree that I am a US resident over the age of 18 and agree to the Terms of Use and Privacy Policy, and site visit recordation by TrustedForm and Jornaya, and I agree to receiving relevant Survey Sailor and The Accident Office emails. By checking the box I consent to receive phone sales calls or SMS text messages - Msg and data rates may apply - from Survey Sailor and The Accident Office on the landline or mobile number I provided even if I am on the federal or state do not call registry. I understand these calls and SMS text messages may be generated using an autodialer and may contain pre-recorded messages and that consenting is not required to participate in the offers promoted. I understand that I may revoke consent at any time. Text STOP to opt out and HELP to receive help. CONTINUE GIFT SAMPLE MIN ENTRIES 8 Nº WINNERS 2 EXP DATE 03/28/2024 Contest Rules GIFT SAMPLE MIN ENTRIES 0 Nº WINNERS EXP DATE 03/28/2024 Contest Rules HOW IT WORKS 1. REGISTER FOR A MONTHLY CONTEST You are now registered for the contest. No other action is required. 2. COMPLETE OPTIONAL SPONSORED QUESTIONNAIRE. Some of these questions may be sponsored by our advertising partners. 3. WE'LL CONTACT WINNERS UPON CONTEST DRAWING. Minimum number of entries are required for contest to be drawn. GENERAL MERCHANT DISCLAIMER The merchants represented are not sponsors of the rewards or otherwise affiliated with this company. The logos and other identifying marks attached are trademarks of and owned by each represented company and/or its affiliates. Please visit each company's website for additional terms and conditions. Present the Terms and Conditions anytime you’re presenting specific gift card use details Terms and Conditions are applied to gift cards. * Privacy * Terms and conditions * Opt out * Contest rules * Unsubscribe * Dispute Notice Copyright © 2023 SurveySailor All Rights Reserved.