<h2>Form Pendaftaran Online Mahasiswa Baru</h2>
<div id="hasil" style=" background-color:#FF0000; color:#FFFFFF; text-align:center;margin-top:15px;"></div>
<form name="frm" method="post" id="frm">
<fieldset>
<legend>Silahkan Isi Form Pendaftaran di Bawah Ini</legend>
<table>
<tr><td>Nama Lengkap</td><td>: <input type="text" name="nama" size="30"></td></tr>
<tr><td>Jenis Kelamin</td><td>: <select name="jeniskelamin" id="jeniskelamin">
<option value="P">Pria</option>
<option value="W">Wanita</option>
</select></td></tr>
<tr><td>Tempat Lahir</td><td>: <input type="text" name="tempat_lahir" size="30"></td></tr>
<tr><td>Tanggal Lahir</td>
<td>: <select size="1" name="tgl" id="Day">
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</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>
<select size="1" name="bln" id="Month" style="margin-left:0px;">
<option value="01">Januari</option>
<option value="02">Februari</option>
<option value="03">Maret</option>
<option value="04">April</option>
<option value="05">Mai</option>
<option value="06">Juni</option>
<option value="07">Juli</option>
<option value="08">Agustus</option>
<option value="09">September</option>
<option value="10">Oktober</option>
<option value="11">November</option>
<option value="12">December</option>
</select>
<select size="1" name="thn" id="Year" style="margin-left:0px;">
<option value='1970'>1970</option><option value='1971'>1971</option><option value='1972'>1972</option><option value='1973'>1973</option><option value='1974'>1974</option><option value='1975'>1975</option><option value='1976'>1976</option><option value='1977'>1977</option><option value='1978'>1978</option><option value='1979'>1979</option><option value='1980'>1980</option><option value='1981'>1981</option><option value='1982'>1982</option><option value='1983'>1983</option><option value='1984'>1984</option><option value='1985'>1985</option><option value='1986'>1986</option><option value='1987'>1987</option><option value='1988'>1988</option><option value='1989'>1989</option><option value='1990'>1990</option><option value='1991'>1991</option><option value='1992'>1992</option><option value='1993'>1993</option><option value='1994'>1994</option><option value='1995'>1995</option><option value='1996'>1996</option><option value='1997'>1997</option><option value='1998'>1998</option><option value='1999'>1999</option><option value='2000'>2000</option><option value='2001'>2001</option><option value='2002'>2002</option><option value='2003'>2003</option><option value='2004'>2004</option><option value='2005'>2005</option><option value='2006'>2006</option><option value='2007'>2007</option><option value='2008'>2008</option><option value='2009'>2009</option><option value='2010'>2010</option><option value='2011'>2011</option><option value='2012'>2012</option> </select>
</td></tr>
<tr><td>Warga Negara</td><td>: <select name="warganegara" id="warganegara">
<option value="WNI">WNI </option>
<option value="WNA">WNA </option>
</select></td></tr>
<tr><td>Agama</td><td>: <select name="agama" id="agama" >
<option value="Islam">Islam</option>
<option value="Kristen">Kristen</option>
<option value="Katolik">Katolik</option>
<option value="Hindu">Hindu</option>
<option value="Budha">Budha</option>
<option value="Khonghucu">Khonghucu</option>
</select></td></tr>
<tr><td>Status Pernikahan</td><td> : <select name="statussipil" id="statussipil" >
<option value="Belum Menikah">Belum Menikah</option>
<option value="Menikah">Menikah</option>
<option value="duda">Duda</option>
<option value="Janda">Janda</option>
</select></td>
</tr>
<tr><td>Alamat</td><td>: <input type="text" name="alamat" size="30"></td></tr>
<tr><td>Tlp / Hp</td><td>: <input type="text" name="tlp" size="30" class="angkasaja"></td></tr>
<tr><td>Ijazah</td><td>: <select name="ijazah" id="ijazah" >
<option value="SMA">SMA</option>
<option value="SMK">SMK</option>
<option value="D1">D1</option>
<option value="D3">D3</option>
<option value="Lain-Lain">Lain-Lain</option>
</select></tr>
<tr><td>No / Tgl Ijazah</td><td>: <input type="text" name="no_ijazah" size="30"></td></tr>
<tr><td>Asal Sekolah</td><td>: <input type="text" name="sekolah_asal" size="30"></td></tr>
<tr><td>Alamat Sekolah</td><td>: <input type="text" name="alamat_sekolah" size="30"></td></tr>
<tr><td>Nama Orang Tua / Wali</td><td>: <input type="text" name="nama_orang_tua" size="30"></td></tr>
<tr><td>Alamat Orang Tua</td><td>: <input type="text" name="alamat_orang_tua" size="30"></td></tr>
<tr><td>Pekerjaan Orang Tua</td><td>: <input type="text" name="kerja_ortu" size="30"></td></tr>
<tr><td>Pilihan Jurusan</td>
<td>: <select name="jurusan" id="jurusan" >
<option value="S1 Teknik Informatika">S1 Teknik Informatika</option>
<option value="D3 Manajemen Informatika">D3 Manajemen Informatika</option>
<option value="Transfer">Mahasiswa Transfer</option>
</select></td></tr>
<tr><td>Pilihan Kelas</td>
<td>: <select name="kelas" id="kelas" >
<option value="Pagi">Kelas Pagi</option>
<option value="Malam">Kelas Malam</option>
</select></td></tr>
<tr><td>* Pekerjaan anda</td><td>: <input type="text" name="pekerjaan" size="30"></td></tr>
<tr><td>* Alamat Kantor anda</td><td>: <input type="text" name="kantor" size="30"></td></tr>
<tr><td><input type="hidden" value="2012/2013" size="30" name="tahun_ajaran"></td></tr>
<tr><td><img src='web/captcha/captcha.php?date=date('YmdHis');' alt='security image'></td><td>: <input type="text" name="verifikasi" id="verifikasi" size="30"></td></tr>
<tr><td></td><td> <input type="submit" value="Kirim Pendaftaran" class="button"/></td></tr>
</table><br />
<div id="keterangan" style=" background-color:#000; color:#FFFFFF; text-align:center;height:30px;padding-top:8px;">
Nb : yang bertanda * wajib diisi bagi yang mengambil KELAS MALAM</div>
</fieldset>
<div class="cleaner_h10"></div>
</form>
