| |
| <FORM action=formulir_act.php method=POST onsubmit="return validate(this);"> |
| <TABLE> |
| <TBODY class=smfont> |
| <TR> |
| <TD colSpan=3></TD></TR> |
| <TR> |
| <TD width=134><STRONG><font size="2">Nama Lengkap</font></STRONG><font size="2"> |
| </font> </TD> |
| <TD colSpan=2><INPUT class=text1 id=nama name=nama> <SPAN>*</SPAN></TD></TR> |
| <TR> |
| <TD><STRONG><font size="2">Tempat, Tgl Lahir </font></STRONG></TD> |
| <TD colSpan=2> |
| <TABLE cellSpacing=0 cellPadding=0 border=0> |
| <TBODY> |
| <TR> |
| <TD vAlign=top width=120><INPUT class=text1 |
| id=Tempat_Lahir name=tempat_lahir></TD> |
| <TD vAlign=top width=9></TD> |
| <TD vAlign=center width=47><SELECT |
| id=tanggal name=tanggal> <OPTION selected>Tgl</OPTION> |
| <OPTION value=1>1</OPTION> <OPTION value=2>2</OPTION> |
| <OPTION value=3>3</OPTION> <OPTION value=4>4</OPTION> |
| <OPTION value=5>5</OPTION> <OPTION value=6>6</OPTION> |
| <OPTION value=7>7</OPTION> <OPTION value=8>8</OPTION> |
| <OPTION value=9>9</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></TD> |
| |
| <TD vAlign=center width=79><SELECT |
| id=bulan name=bulan> <OPTION selected>Bulan</OPTION> |
| <OPTION value=Januari>Januari</OPTION> <OPTION |
| value=Februari>Februari</OPTION> <OPTION |
| value=Maret>Maret</OPTION> <OPTION |
| value=April>April</OPTION> <OPTION |
| value=Mei>Mei</OPTION> <OPTION |
| value=Juni>Juni</OPTION> <OPTION |
| value=Juli>Juli</OPTION> <OPTION |
| value=Agustus>Agustus</OPTION> <OPTION |
| value=September>September</OPTION> <OPTION |
| value=Oktober>Oktober</OPTION> <OPTION |
| value=November>November</OPTION> <OPTION |
| value=Desember>Desember</OPTION></SELECT></TD> |
| |
| <TD vAlign=center width=104><INPUT class=text1 id=Tahun |
| maxLength=4 size=5 name=tahun></TD></TR></TBODY></TABLE></TD></TR> |
| <TR> |
| <TD><STRONG><font size="2">Telepon</font></STRONG><font size="2"> |
| </font> </TD> |
| <TD colSpan=2><INPUT class=text1 id=no_telepon |
| name=no_telepon> <SPAN >* </SPAN></TD></TR> |
| <TR> |
| <TD><STRONG><font size="2">Email </font> </STRONG></TD> |
| <TD colSpan=2><INPUT class=text1 id=surat name=surat> <SPAN |
| >* </SPAN></TD></TR> |
| <TR> |
| <TD><STRONG><font size="2">Kota </font> </STRONG></TD> |
| <TD colSpan=2><SPAN> |
| <SELECT id=Wilayah |
| name=wilayah size="1"> <OPTION selected>-- Pilih Kota --</OPTION> |
| <OPTION value="Jakarta Pusat">Jakarta Pusat</OPTION> <OPTION |
| value="Jakarta Barat">Jakarta Barat</OPTION> <OPTION |
| value="Jakarta Timur">Jakarta Timur</OPTION> <OPTION |
| value="Jakarta Utara">Jakarta Utara</OPTION> <OPTION |
| value="Jakarta Selatan">Jakarta Selatan</OPTION> <OPTION |
| value=Bekasi>Bekasi</OPTION> <OPTION |
| value=Tangerang>Tangerang</OPTION> <OPTION |
| value=Depok>Depok</OPTION> <OPTION |
| value=Bogor>Bogor</OPTION></SELECT> <SPAN |
| >*</SPAN></SPAN></TD></TR> |
| <TR> |
| <TD vAlign=top><STRONG><font size="2">Alamat Rumah </font> </STRONG></TD> |
| <TD width=340> |
| <TEXTAREA class=text1 id=alamat name=alamat rows=7 cols=40></TEXTAREA></TD> |
| <TD vAlign=center width=90><SPAN >*</SPAN></TD></TR> |
| <TR> |
| <TD colSpan=3> |
| <TABLE cellSpacing=0 cellPadding=0 border=0> |
| <TBODY> |
| <TR> |
| <TD vAlign=top><font color="#999999" size="2"><strong>Merek & Tipe Motor </strong></font></TD> |
| <TD> |
| <SELECT id=s_mc size=1 name=pilihanmotor class="dd"> |
| <option>-</option> |
