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  1. <body>
  2. <head>
  3. <meta charset="UTF-8">
  4. </head>
  5. <center>
  6. <script src="https://cdn.jotfor.ms/js/vendor/imageinfo.js?v=3.3.9982" type="text/javascript"></script>
  7. <script src="https://cdn.jotfor.ms/file-uploader/fileuploader.js?v=3.3.9982"></script>
  8. <script src="https://cdn.jotfor.ms/static/prototype.forms.js" type="text/javascript"></script>
  9. <script src="https://cdn.jotfor.ms/static/jotform.forms.js?3.3.9982" type="text/javascript"></script>
  10. <script type="text/javascript">
  11. JotForm.init(function(){
  12.  
  13. JotForm.calendarMonths = ["January","February","March","April","May","June","July","August","September","October","November","December"];
  14. JotForm.calendarDays = ["Sunday","Monday","Tuesday","Wednesday","Thursday","Friday","Saturday","Sunday"];
  15. JotForm.calendarOther = {"today":"Today"};
  16. var languageOptions = document.querySelectorAll('#langList li');
  17. for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) {
  18. languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar("8", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""}); }, 0); });
  19. }
  20. JotForm.setCalendar("8", false, {"days":{"monday":true,"tuesday":true,"wednesday":true,"thursday":true,"friday":true,"saturday":true,"sunday":true},"future":true,"past":true,"custom":false,"ranges":false,"start":"","end":""});
  21. JotForm.initCaptcha('input_14');
  22. $('input_14_reload').observe('click',function(){ JotForm.reloadCaptcha('input_14') })
  23. JotForm.alterTexts({"alphabetic":"Este campo pode conter apenas letras","alphanumeric":"Este campo só pode conter letras e números.","ccDonationMinLimitError":"Valor mínimo é {minAmount} {currency}","ccInvalidCVC":"Single Product w/ Single Choice Orders ","ccInvalidExpireDate":"Data de expiração inválida.","ccInvalidNumber":"Número do cartão de crédito é inválido.","ccMissingDetails":"Por favor, preencha os detalhes do Cartão de Crédito.","ccMissingDonation":"Por favor, indique valores numéricos para montante da doação.","ccMissingProduct":"Por favor, selecione pelo menos um produto.","characterLimitError":"Muitos caracteres. O limite é de","characterMinLimitError":"Muito poucos caracteres. O mínimo é","confirmClearForm":"Você tem certeza que quer limpar este formulário","confirmEmail":"E-mail não confere","currency":"Este campo apenas admite valores monetários.","cyrillic":"Este campo aceita apenas caracteres cirilicos.","dateInvalid":"Esta data não é válida. O formato da data é {format}","dateInvalidSeparate":"Esta data não é válido. Insira um válido {element}.","dateLimited":"Esta data não está disponível.","disallowDecimals":"Por favor insira um número inteiro.","email":"Digite um endereço de e-mail válido.","fillMask":"Valor do campo deve preencher máscara.","freeEmailError":"Não são permitidas contas de email gratuitas","generalError":"Existem erros no formulário. Por favor corrigi-los antes de continuar.","generalPageError":"Há erros nesta página. Por favor, corrija-os antes de continuar.","gradingScoreError":"Pontuação total deve ser menor ou igual a ","incompleteFields":"Há campos obrigatórios incompletos. Por favor, preencha-os.","inputCarretErrorA":"A entrada não deve ser menor do que o valor mínimo:","inputCarretErrorB":"Valor não deve ser maior do que o máximo:","lessThan":"A sua pontuação deve ser inferior ou igual a","maxDigitsError":"O numero máximo de caracteres permitidos são","maxSelectionsError":"O número máximo de seleções permitidas é","minSelectionsError":"O número mínimo exigido de seleções é","multipleFileUploads_emptyError":"{file} está vazio, por favor selecione os arquivos de novo.","multipleFileUploads_fileLimitError":"Somente são permitidos {fileLimit} envios de arquivos","multipleFileUploads_minSizeError":"{file} é muito pequeno, o tamanho mínimo do arquivo é {minSizeLimit}.","multipleFileUploads_onLeave":"Os arquivos agora estão em upload, se você sair agora o upload será cancelado.","multipleFileUploads_sizeError":"{file} é muito grande, o tamanho máximo é {sizeLimit}.","multipleFileUploads_typeError":"O arquivo {file} é inválido, pois somente as extensões {extensions} são permitidas.","numeric":"Este campo pode conter apenas números","pastDatesDisallowed":"A data não pode ser passada.","required":"Este campo é obrigatório.","requireEveryCell":"Toda célula é requisitada.","requireEveryRow":"Todos os campos são requeridos.","requireOne":"Pelo menos um campo é requisitado.","uploadExtensions":"Só pode fazer upload dos seguintes ficheiros:","uploadFilesize":"O tamanho do arquivo não pode ser maior que:","uploadFilesizemin":"O ficheiro não pode ser menor que:","url":"Este campo apenas pode conter um URL válido","wordLimitError":"Demasiadas palavras. O limite é de","wordMinLimitError":"Muito poucas palavras. O mínimo é"});
  24. JotForm.clearFieldOnHide="disable";
  25. setTimeout(function() {
  26. JotForm.initMultipleUploads();
  27. }, 2);
  28. JotForm.submitError="jumpToFirstError";
  29. /*INIT-END*/
  30. });
  31.  
  32. JotForm.prepareCalculationsOnTheFly([null,{"name":"heading","qid":"1","text":"Confirmacao de Doacao BGE","type":"control_head"},{"name":"submit2","qid":"2","text":"Enviar","type":"control_button"},{"description":"","name":"nomeCompleto","qid":"3","text":"Nome Completo","type":"control_fullname"},{"description":"","name":"nickIngame","qid":"4","subLabel":"","text":"Nick In-game","type":"control_textbox"},{"description":"","name":"email","qid":"5","subLabel":"example@example.com","text":"E-mail","type":"control_email"},null,{"description":"","name":"numeroDe7","qid":"7","text":"Numero de Contato","type":"control_phone"},{"description":"","name":"dataDo","qid":"8","text":"Data do Pagamento","type":"control_datetime"},{"description":"","name":"horarioDo","qid":"9","text":"Horario do Pagamento","type":"control_time"},{"description":"","name":"valorPago","qid":"10","subLabel":"","text":"Valor Pago","type":"control_textbox"},null,{"description":"","name":"qualMetodo","qid":"12","subLabel":"","text":"Qual metodo de Pagamento?","type":"control_dropdown"},{"description":"","name":"envieUma","qid":"13","subLabel":"","text":"Envie uma imagem do comprovante de pagamento","type":"control_fileupload"},{"description":"","name":"coloqueA","qid":"14","text":"Coloque a mensagem como e mostrada","type":"control_captcha"},{"name":"cliquePara","qid":"15","text":"Confirme apenas UMA VEZ e aguarde, temos at&eacute; 72 horas para lhe entregar.","type":"control_text"}]);
  33. setTimeout(function() {
  34. JotForm.paymentExtrasOnTheFly([null,{"name":"heading","qid":"1","text":"Confirmacao de Doacao BGE","type":"control_head"},{"name":"submit2","qid":"2","text":"Enviar","type":"control_button"},{"description":"","name":"nomeCompleto","qid":"3","text":"Nome Completo","type":"control_fullname"},{"description":"","name":"nickIngame","qid":"4","subLabel":"","text":"Nick In-game","type":"control_textbox"},{"description":"","name":"email","qid":"5","subLabel":"example@example.com","text":"E-mail","type":"control_email"},null,{"description":"","name":"numeroDe7","qid":"7","text":"Numero de Contato","type":"control_phone"},{"description":"","name":"dataDo","qid":"8","text":"Data do Pagamento","type":"control_datetime"},{"description":"","name":"horarioDo","qid":"9","text":"Horario do Pagamento","type":"control_time"},{"description":"","name":"valorPago","qid":"10","subLabel":"","text":"Valor Pago","type":"control_textbox"},null,{"description":"","name":"qualMetodo","qid":"12","subLabel":"","text":"Qual metodo de Pagamento?","type":"control_dropdown"},{"description":"","name":"envieUma","qid":"13","subLabel":"","text":"Envie uma imagem do comprovante de pagamento","type":"control_fileupload"},{"description":"","name":"coloqueA","qid":"14","text":"Coloque a mensagem como e mostrada","type":"control_captcha"},{"name":"cliquePara","qid":"15","text":"Confirme apenas UMA VEZ e aguarde, temos at&eacute; 72 horas para lhe entregar.","type":"control_text"}]);}, 20);
  35. </script>
  36. <link href="https://cdn.jotfor.ms/static/formCss.css?3.3.9982" rel="stylesheet" type="text/css" />
  37. <link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/nova.css?3.3.9982" />
  38. <link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.9982" />
  39. <link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/themes/CSS/566a91c2977cdfcd478b4567.css?"/>
  40. <style type="text/css">
  41. .form-label-left{
  42. width:150px;
  43. }
  44. .form-line{
  45. padding-top:12px;
  46. padding-bottom:12px;
  47. }
  48. .form-label-right{
  49. width:150px;
  50. }
  51. .form-all{
  52. width:690px;
  53. color:#6a4a3c !important;
  54. font-family:"Lucida Grande", "Lucida Sans Unicode", "Lucida Sans", Verdana, sans-serif;
  55. font-size:14px;
  56. }
  57. </style>
  58.  
  59. <style type="text/css" id="form-designer-style">
  60. /* Injected CSS Code */
  61. .form-label.form-label-auto { display: block; float: none; text-align: left; width: inherit; } /*PREFERENCES STYLE*/
  62. .form-all {
  63. font-family: Lucida Grande, sans-serif;
  64. }
  65. .form-all .qq-upload-button,
  66. .form-all .form-submit-button,
  67. .form-all .form-submit-reset,
  68. .form-all .form-submit-print {
  69. font-family: Lucida Grande, sans-serif;
  70. }
  71. .form-all .form-pagebreak-back-container,
  72. .form-all .form-pagebreak-next-container {
  73. font-family: Lucida Grande, sans-serif;
  74. }
  75. .form-header-group {
  76. font-family: Lucida Grande, sans-serif;
  77. }
  78. .form-label {
  79. font-family: Lucida Grande, sans-serif;
  80. }
  81.  
  82. .form-label.form-label-auto {
  83.  
  84. display: block;
  85. float: none;
  86. text-align: left;
  87. width: 100%;
  88.  
  89. }
  90.  
  91. .form-line {
  92. margin-top: 12px;
  93. margin-bottom: 12px;
  94. }
  95.  
  96. .form-all {
  97. width: 690px;
  98. }
  99.  
  100. .form-label-left,
  101. .form-label-right,
  102. .form-label-left.form-label-auto,
  103. .form-label-right.form-label-auto {
  104. width: 150px;
  105. }
  106.  
  107. .form-all {
  108. font-size: 14px
  109. }
  110. .form-all .qq-upload-button,
  111. .form-all .qq-upload-button,
  112. .form-all .form-submit-button,
  113. .form-all .form-submit-reset,
  114. .form-all .form-submit-print {
  115. font-size: 14px
  116. }
  117. .form-all .form-pagebreak-back-container,
  118. .form-all .form-pagebreak-next-container {
  119. font-size: 14px
  120. }
  121.  
  122. .supernova .form-all, .form-all {
  123. background-color: #b8e986;
  124. border: 1px solid transparent;
  125. }
  126.  
  127. .form-all {
  128. color: #6a4a3c;
  129. }
  130. .form-header-group .form-header {
  131. color: #6a4a3c;
  132. }
  133. .form-header-group .form-subHeader {
  134. color: #6a4a3c;
  135. }
  136. .form-label-top,
  137. .form-label-left,
  138. .form-label-right,
  139. .form-html,
  140. .form-checkbox-item label,
  141. .form-radio-item label {
  142. color: #6a4a3c;
  143. }
  144. .form-sub-label {
  145. color: #846456;
  146. }
  147.  
  148. .supernova {
  149. background-color: #eb6841;
  150. }
  151. .supernova body {
  152. background: transparent;
  153. }
  154.  
  155. .form-textbox,
  156. .form-textarea,
  157. .form-radio-other-input,
  158. .form-checkbox-other-input,
  159. .form-captcha input,
  160. .form-spinner input {
  161. background-color: #fff;
  162. }
  163.  
  164. .supernova {
  165. height: 100%;
  166. background-repeat: repeat;
  167. background-attachment: scroll;
  168. background-position: center top;
  169. }
  170. .supernova {
  171. background-image: url("https://www.phishing-site.www/uploads/XxJohnSilvaxX/form_files/fundo1.5c66c5f80dd7a5.16774038.png");
  172. }
  173. #stage {
  174. background-image: url("https://www.phishing-site.www/uploads/XxJohnSilvaxX/form_files/fundo1.5c66c5f80dd7a5.16774038.png");
  175. }
  176.  
  177. .form-all {
  178. background-image: none;
  179. }
  180.  
  181. .ie-8 .form-all:before { display: none; }
  182. .ie-8 {
  183. margin-top: auto;
  184. margin-top: initial;
  185. }
  186. body{background-color:red}
  187.  
  188. /*PREFERENCES STYLE*//*__INSPECT_SEPERATOR__*/
  189. /* Injected CSS Code */
  190. </style>
  191.  
  192. <form class="jotform-form" action="https://submit.jotformz.com/submit/90453373789671/" method="post" enctype="multipart/form-data" name="form_90453373789671" id="90453373789671" accept-charset="utf-8">
  193. <input type="hidden" name="formID" value="90453373789671" />
  194. <div class="form-all">
  195. <ul class="form-section page-section">
  196. <li id="cid_1" class="form-input-wide" data-type="control_head">
  197. <div class="form-header-group ">
  198. <div class="header-text httal htvam">
  199. <h2 id="header_1" class="form-header" data-component="header">
  200. Confirmação de Doação BGE
  201. </h2>
  202. </div>
  203. </div>
  204. </li>
  205. <li class="form-line" data-type="control_text" id="id_15">
  206. <div id="cid_15" class="form-input-wide">
  207. <div id="text_15" class="form-html" data-component="text">
  208. <p>Confirme apenas UMA VEZ e aguarde, temos até 72 horas para lhe entregar.</p>
  209. </div>
  210. </div>
  211. </li>
  212. <li class="form-line" data-type="control_fullname" id="id_3">
  213. <label class="form-label form-label-top form-label-auto" id="label_3" for="first_3"> Nome Completo </label>
  214. <div id="cid_3" class="form-input-wide">
  215. <div data-wrapper-react="true">
  216. <span class="form-sub-label-container" style="vertical-align:top">
  217. <input type="text" id="first_3" name="q3_nomeCompleto[first]" class="form-textbox" size="10" value="" data-component="first" />
  218. <label class="form-sub-label" for="first_3" id="sublabel_first" style="min-height:13px"> Nome próprio </label>
  219. </span>
  220. <span class="form-sub-label-container" style="vertical-align:top">
  221. <input type="text" id="last_3" name="q3_nomeCompleto[last]" class="form-textbox" size="15" value="" data-component="last" />
  222. <label class="form-sub-label" for="last_3" id="sublabel_last" style="min-height:13px"> Sobrenome </label>
  223. </span>
  224. </div>
  225. </div>
  226. </li>
  227. <li class="form-line" data-type="control_textbox" id="id_4">
  228. <label class="form-label form-label-top form-label-auto" id="label_4" for="input_4"> Nick In-game </label>
  229. <div id="cid_4" class="form-input-wide">
  230. <input type="text" id="input_4" name="q4_nickIngame" data-type="input-textbox" class="form-textbox" size="20" value="" data-component="textbox" />
  231. </div>
  232. </li>
  233. <li class="form-line" data-type="control_email" id="id_5">
  234. <label class="form-label form-label-top form-label-auto" id="label_5" for="input_5"> E-mail </label>
  235. <div id="cid_5" class="form-input-wide">
  236. <span class="form-sub-label-container" style="vertical-align:top">
  237. <input type="email" id="input_5" name="q5_email" class="form-textbox validate[Email]" size="30" value="" data-component="email" />
  238. <label class="form-sub-label" for="input_5" style="min-height:13px"> example@example.com </label>
  239. </span>
  240. </div>
  241. </li>
  242. <li class="form-line" data-type="control_phone" id="id_7">
  243. <label class="form-label form-label-top form-label-auto" id="label_7" for="input_7_area"> Número de Contato </label>
  244. <div id="cid_7" class="form-input-wide">
  245. <div data-wrapper-react="true">
  246. <span class="form-sub-label-container" style="vertical-align:top">
  247. <input type="tel" id="input_7_area" name="q7_numeroDe7[area]" class="form-textbox" size="6" value="" data-component="areaCode" />
  248. <span class="phone-separate">
  249. -
  250. </span>
  251. <label class="form-sub-label" for="input_7_area" id="sublabel_area" style="min-height:13px"> Código de área </label>
  252. </span>
  253. <span class="form-sub-label-container" style="vertical-align:top">
  254. <input type="tel" id="input_7_phone" name="q7_numeroDe7[phone]" class="form-textbox" size="12" value="" data-component="phone" />
  255. <label class="form-sub-label" for="input_7_phone" id="sublabel_phone" style="min-height:13px"> Número de Telefone </label>
  256. </span>
  257. </div>
  258. </div>
  259. </li>
  260. <li class="form-line" data-type="control_time" id="id_9">
  261. <label class="form-label form-label-top form-label-auto" id="label_9" for="input_9_hourSelect"> Horário do Pagamento </label>
  262. <div id="cid_9" class="form-input-wide">
  263. <div data-wrapper-react="true">
  264. <span class="form-sub-label-container" style="vertical-align:top">
  265. <select class="time-dropdown form-dropdown" id="input_9_hourSelect" name="q9_horarioDo[hourSelect]" data-component="time-hour">
  266. <option> </option>
  267. <option value="1"> 1 </option>
  268. <option value="2"> 2 </option>
  269. <option value="3"> 3 </option>
  270. <option value="4"> 4 </option>
  271. <option value="5"> 5 </option>
  272. <option value="6"> 6 </option>
  273. <option value="7"> 7 </option>
  274. <option value="8"> 8 </option>
  275. <option value="9"> 9 </option>
  276. <option value="10"> 10 </option>
  277. <option value="11"> 11 </option>
  278. <option value="12"> 12 </option>
  279. </select>
  280. <span class="date-separate">
  281. :
  282. </span>
  283. <label class="form-sub-label" for="input_9_hourSelect" id="sublabel_hour" style="min-height:13px"> Hora </label>
  284. </span>
  285. <span class="form-sub-label-container" style="vertical-align:top">
  286. <select class="time-dropdown form-dropdown" id="input_9_minuteSelect" name="q9_horarioDo[minuteSelect]" data-component="time-minute">
  287. <option> </option>
  288. <option value="00"> 00 </option>
  289. <option value="10"> 10 </option>
  290. <option value="20"> 20 </option>
  291. <option value="30"> 30 </option>
  292. <option value="40"> 40 </option>
  293. <option value="50"> 50 </option>
  294. </select>
  295. <label class="form-sub-label" for="input_9_minuteSelect" id="sublabel_minutes" style="min-height:13px"> Minutos </label>
  296. </span>
  297. <span class="form-sub-label-container" style="vertical-align:top">
  298. <select class="time-dropdown form-dropdown" id="input_9_ampm" name="q9_horarioDo[ampm]" data-component="time-ampm">
  299. <option value="AM"> AM </option>
  300. <option selected="" value="PM"> PM </option>
  301. </select>
  302. <label class="form-sub-label" for="input_9_ampm" style="min-height:13px"> </label>
  303. </span>
  304. </div>
  305. </div>
  306. </li>
  307. <li class="form-line" data-type="control_datetime" id="id_8">
  308. <label class="form-label form-label-top form-label-auto" id="label_8" for="lite_mode_8"> Data do Pagamento </label>
  309. <div id="cid_8" class="form-input-wide">
  310. <div data-wrapper-react="true">
  311. <div style="display:none">
  312. <span class="form-sub-label-container" style="vertical-align:top">
  313. <input type="tel" class="form-textbox validate[limitDate]" id="month_8" name="q8_dataDo[month]" size="2" data-maxlength="2" value="" />
  314. <span class="date-separate">
  315. -
  316. </span>
  317. <label class="form-sub-label" for="month_8" id="sublabel_month" style="min-height:13px"> Mês </label>
  318. </span>
  319. <span class="form-sub-label-container" style="vertical-align:top">
  320. <input type="tel" class="form-textbox validate[limitDate]" id="day_8" name="q8_dataDo[day]" size="2" data-maxlength="2" value="" />
  321. <span class="date-separate">
  322. -
  323. </span>
  324. <label class="form-sub-label" for="day_8" id="sublabel_day" style="min-height:13px"> dia </label>
  325. </span>
  326. <span class="form-sub-label-container" style="vertical-align:top">
  327. <input type="tel" class="form-textbox validate[limitDate]" id="year_8" name="q8_dataDo[year]" size="4" data-maxlength="4" value="" />
  328. <label class="form-sub-label" for="year_8" id="sublabel_year" style="min-height:13px"> Ano </label>
  329. </span>
  330. </div>
  331. <span class="form-sub-label-container" style="vertical-align:top">
  332. <input type="text" class="form-textbox validate[limitDate, validateLiteDate]" id="lite_mode_8" size="12" data-maxlength="12" data-age="" value="" data-format="mmddyyyy" data-seperator="-" placeholder="mm-dd-yyyy" />
  333. <img alt="Pick a Date" id="input_8_pick" src="https://cdn.jotfor.ms/images/calendar.png" style="vertical-align:middle;margin-left:5px" data-component="datetime" />
  334. <label class="form-sub-label" for="lite_mode_8" id="sublabel_litemode" style="min-height:13px"> Data </label>
  335. </span>
  336. <span class="form-sub-label-container" style="vertical-align:top">
  337. <label class="form-sub-label" for="input_8_pick" style="min-height:13px"> </label>
  338. </span>
  339. </div>
  340. </div>
  341. </li>
  342. <li class="form-line" data-type="control_textbox" id="id_10">
  343. <label class="form-label form-label-top form-label-auto" id="label_10" for="input_10"> Valor Pago </label>
  344. <div id="cid_10" class="form-input-wide">
  345. <input type="text" id="input_10" name="q10_valorPago" data-type="input-textbox" class="form-textbox" size="20" value="" data-component="textbox" />
  346. </div>
  347. </li>
  348. <li class="form-line" data-type="control_dropdown" id="id_12">
  349. <label class="form-label form-label-top form-label-auto" id="label_12" for="input_12"> Qual método de Pagamento? </label>
  350. <div id="cid_12" class="form-input-wide">
  351. <select class="form-dropdown" id="input_12" name="q12_qualMetodo" style="width:150px" data-component="dropdown">
  352. <option value=""> </option>
  353. <option value="Depósito em Conta"> Depósito em Conta </option>
  354. <option value="PagSeguro"> PagSeguro </option>
  355. <option value="Paypal"> Paypal </option>
  356. </select>
  357. </div>
  358. </li>
  359. <li class="form-line" data-type="control_fileupload" id="id_13">
  360. <label class="form-label form-label-top form-label-auto" id="label_13" for="input_13"> Envie uma imagem do comprovante de pagamento </label>
  361. <div id="cid_13" class="form-input-wide">
  362. <div data-wrapper-react="true">
  363. <div data-wrapper-react="true">
  364. <div class="qq-uploader-buttonText-value">
  365. Browse Files
  366. </div>
  367. <input type="file" id="input_13" name="q13_envieUma[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif" data-file-maxsize="10854" data-file-minsize="0" data-file-limit="" data-component="fileupload" />
  368. </div>
  369. <span style="display:none" class="cancelText">
  370. Cancel
  371. </span>
  372. <span style="display:none" class="ofText">
  373. of
  374. </span>
  375. </div>
  376. </div>
  377. </li>
  378. <li class="form-line jf-required" data-type="control_captcha" id="id_14">
  379. <label class="form-label form-label-top form-label-auto" id="label_14" for="input_14">
  380. Coloque a mensagem como é mostrada
  381. <span class="form-required">
  382. *
  383. </span>
  384. </label>
  385. <div id="cid_14" class="form-input-wide jf-required">
  386. <div class="form-captcha" data-component="captcha">
  387. <label for="input_14"> <img alt="Captcha - Reload if not displayed" id="input_14_captcha" class="form-captcha-image" style="background:url(https://cdn.jotfor.ms/images/loader-big.gif) no-repeat center" src="https://cdn.jotfor.ms/images/blank.gif" width="150" height="41" /> </label>
  388. <div style="white-space:nowrap">
  389. <input type="text" id="input_14" class="form-textbox validate[required]" name="captcha" style="width:130px" required="" />
  390. <img src="https://cdn.jotfor.ms/images/reload.png" alt="Reload" style="cursor:pointer;vertical-align:middle" id="input_14_reload" />
  391. <input type="hidden" name="captcha_id" id="input_14_captcha_id" value="0" />
  392. </div>
  393. </div>
  394. </div>
  395. </li>
  396. <li class="form-line" data-type="control_button" id="id_2">
  397. <div id="cid_2" class="form-input-wide">
  398. <div style="margin-left:156px" class="form-buttons-wrapper">
  399. <button id="input_2" type="submit" class="form-submit-button" data-component="button">
  400. Enviar
  401. </button>
  402. </div>
  403. </div>
  404. </li>
  405. <li style="display:none">
  406. Should be Empty:
  407. <input type="text" name="website" value="" />
  408. </li>
  409. </ul>
  410. </div>
  411. <script>
  412. JotForm.showJotFormPowered = "new_footer";
  413. </script>
  414. <input type="hidden" id="simple_spc" name="simple_spc" value="90453373789671" />
  415. <script type="text/javascript">
  416. document.getElementById("si" + "mple" + "_spc").value = "90453373789671-90453373789671";
  417. </script>
  418. <div class="formFooter-heightMask">
  419. </div>
  420. <div class="formFooter f6">
  421. <a href="https://www.phishing-site.www/pricing?utm_source=formfooter&utm_medium=banner&utm_term=90453373789671&utm_content=jotform_logo&utm_campaign=powered_by_jotform_le" target="_blank" class="formFooter-logoLink"><img class="formFooter-logo" src="https://cdn.jotfor.ms/assets/img/logo/logo-new@1x.png" alt="" style="height: 44px;"></a>
  422. <div class="formFooter-rightSide">
  423. <span class="formFooter-text">
  424. Now create your own JotForm - It's free!
  425. </span>
  426. <a class="formFooter-button" href="https://www.phishing-site.www/?utm_source=formfooter&utm_medium=banner&utm_term=90453373789671&utm_content=jotform_button&utm_campaign=powered_by_jotform_le" target="_blank">Create your own JotForm</a>
  427. </div>
  428. </div>
  429. </form>
  430. <script type="text/javascript">JotForm.ownerView=true;</script>
  431. </center>
  432. </body>
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