PAL.C.T MINI SHELL
<?php
echo "<div class='news_tittle'>
<h4> Daftar </h4>
</div>
<div class='col-xs-12'>
<form name=form action=proses-daftar.html method=POST onSubmit=\"return validasi(this)\">
<table>
<tr>
<td><span class=red>*</span> Nama Lengkap</td>
<td> : </td>
<td><input type=text name=nama size=30 class='form-control'></td>
</tr>
<tr>
<td> <span class=red>*</span> Email</td>
<td> :</td>
<td> <input type=text name=email size=30 class='form-control'></td>
</tr>
<tr>
<td> <span class=red>*</span> Password</td>
<td> : </td>
<td><input type=text name=password size=30 class='form-control'></td>
</tr>
<tr>
<td>Perusahaan</td>
<td> : </td>
<td><input type=text name=perusahaan size=30 class='form-control'></td>
</tr>
<tr>
<td><span class=red>*</span>Alamat Pengiriman</td>
<td> : </td>
<td><textarea 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 type=text name=kota class='form-control'></td>
</tr>
<tr>
<td><span class=red>*</span>Kodepos</td>
<td> : </td>
<td><input type=text name=kodepos class='form-control'></td>
</tr>
<tr>
<td>Telpon/HP</td>
<td> : </td>
<td><input 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><span class=red>*</span>Metode Pengiriman</td>
<td> : </td>
<td><select name='metode_pengiriman' class='form-control'>
<option value='toko'>Ambil di Toko</option>
<option value='paket'>Kirim Paket</option>
</select>
</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='Register'>
</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>
";
?>
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