PAL.C.T MINI SHELL
<div class="col-md-3">
<div class="news_tittle">
<h4> Kami Berada di </h4>
</div>
<p>
<b>FAEDAH Hardware & Tools</b><br>
Jl. Bogor No. 40 Medan
20212 Indonesia<br>
Fax 456-9174<br>
<span class='glyphicon glyphicon-earphone'></span> (061) 456-8886<br>
<span class='glyphicon glyphicon-envelope'></span> b2b@faedahteknik.com<br>
<span class='glyphicon glyphicon-globe'></span> <a href="<?php echo $base_url; ?>">www.faedahteknik.com</a>
</p>
<div id="googleMap" class='col-md-12' style="height:200px;"></div>
<br><br>
</div>
<div class="col-md-9">
<div class='news_tittle'>
<h4> Hubungi Kami </h4>
</div>
<div class="col-md-12 ">
<form role="form" method="POST" class="form-horizontal" action="aksi-hubungi-kami.html" enctype='multipart/form-data'>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Nama</label>
<div class="col-sm-8">
<input name="nama" type="text" placeholder="Nama Anda" class="form-control">
</div>
</div>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Email</label>
<div class="col-sm-8">
<input name="email" type="email" id="exampleInputEmail1" placeholder="Email" class="form-control">
</div>
</div>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Ponsel</label>
<div class="col-sm-8">
<input name="phone" type="text" placeholder="No.Ponsel" class="form-control">
</div>
</div>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Topik</label>
<div class="col-sm-8">
<select name='topik' class="form-control">
<option value='Inquiry / PreSaless'> Inquiry / PreSales </option>
<option value='Produk Info / Detail Produk'> Produk Info / Detail Produk </option>
<option value='Komplain / Waranty'> Komplain / Waranty </option>
<option value='Others'> Others </option>
</select>
</div>
</div>
<div class="form-group">
<label class="col-sm-3 control-label" ><span class='red'>*</span>Subjek</label>
<div class="col-sm-8">
<input name="subjek" type="text" placeholder="Subjek" class="form-control">
</div>
</div>
<div class="form-group">
<label class="col-sm-3 control-label" >Komentar / Pesan</label>
<div class="col-sm-8">
<textarea class="form-control" name="isi_testimoni" cols="40"></textarea>
</div>
</div>
<div class="form-group">
<div class="col-sm-offset-3 col-sm-9">
<button class="btn btn-primary" type="submit">Submit</button>
<br><br><i>Note : Form yang bertanda <span class='red'>*</span> harus di isi.</i>
</div>
</div>
</form>
</div>
<br><br>
<div class='news_tittle'>
<h4> Permintaan Member </h4>
</div>
<div class='col-md-8 col-md-offset-2'>
<form name=form id=myForm action=priview.html method=POST onSubmit=\"return validasi(this)\">
<table>
<tr>
<td><span class=red>*</span> Nama Lengkap</td>
<td> : </td>
<td><input id=nama type=text name=nama size=30 class='form-control'></td>
</tr>
<tr>
<td> <span class=red>*</span> Email</td>
<td> :</td>
<td> <input id=email type=email name=email size=30 class='form-control'></td>
</tr>
<tr>
<td> <span class=red>*</span> Password</td>
<td> : </td>
<td><input id='password' type=password name=password size=30 class='form-control'></td>
</tr>
<tr>
<td> <span class=red>*</span> Ulangi Password</td>
<td> : </td>
<td><input id='ulangi_password' type=password name=ulangi_password size=30 class='form-control'></td>
</tr>
<tr>
<td>Perusahaan</td>
<td> : </td>
<td><input id='perusahaan' type=text name=perusahaan size=30 class='form-control'></td>
</tr>
<tr>
<td><span class=red>*</span>Alamat Pengiriman</td>
<td> : </td>
<td><textarea id='alamat' name='alamat' rows='3' cols='50' class='form-control'></textarea></td>
</tr>
<tr>
<td></td><td></td><td> Alamat pengiriman harus di isi lengkap, termasuk kota/kabupaten dan kode posnya.</td>
</tr>
<tr>
<td><span class='red'>*</span>Kota</td>
<td> : </td>
<td><input id='kota' type=text name=kota class='form-control'></td>
</tr>
<tr>
<td><span class=red>*</span>Kodepos</td>
<td> : </td>
<td><input id='kodepos' type=text name=kodepos class='form-control'></td>
</tr>
<tr>
<td><span class='red'>*</span>Telpon/HP</td>
<td> : </td>
<td><input id='telpon' type=text name=telpon class='form-control'></td>
</tr>
<tr>
<td>Fax</td>
<td> : </td>
<td><input type=text name=fax class='form-control'></td>
</tr>
<tr>
<td>NPWP</td>
<td> : </td>
<td><input type=text name=npwp class='form-control'></td>
</tr>
<tr><td colspan=2><br><input type='submit' class='btn btn-primary' value='Kirim Permintaan'>
</td>
<td><br><a href='javascript:history.go(-1)' class='btn btn-warning'>Kembali</a></td>
</tr>
</table>
<br><i>Note : Form yang bertanda <span class='red'>*</span> harus di isi.</i>
</form>
</div>
</div>
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