<form role="form" id='registration-form' method="post" action="act-customer.php" onSubmit="return validasi(this)">
                    <h5>Nama Penerima</h5>
                    <input type='text' name='penerima' class='form-control' required>
                    </p>
                    <h5>Nomor Contact</h5>
                    <input type='text' name='telpon' class='form-control' required>
                    </p>
                    <h5>Alamat</h5>
                    <textarea  name='alamat'class="form-control" rows="3" required></textarea>
                    </p>
                    <h5>Kode Pos</h5>
                    <input type='text' name='kodepos' class='form-control' required>
                    </p>
                    <?php
                    include "config/con_db.php";
                    echo" <h5>Kota Tujuan</h5>
                            <select name='kota' class=form-control  required>
                            <option value=0 selected>- Pilih Kota -</option>";
                    $tampil=mysql_query("SELECT * FROM ongkoskirim ORDER BY KotaTujuan");
                    if ($r[IdKota]==0){
                    echo "<option value=0 selected>- Pilih Kota -</option>"; }
                            while($w=mysql_fetch_array($tampil)){
                            if ($r[IdKota]==$w[IdKota]){
                            echo "<option value=$w[IdKota] selected>$w[KotaTujuan]</option>";
                        }
                    else{
                    echo "<option value=$w[IdKota]>$w[KotaTujuan]</option>"; }
                    }
                    echo"</select>";
                    ?>
                    </p>
                    <?php include "config/con_db.php";
                    echo" <h5>Jasa Pengiriman</h5>
                            <select name='kurir' id='kategori' class=form-control required>
                            <option value=0 selected>- Pilih Jasa Pengiriman -</option>";
                            $tampil=mysql_query("SELECT * FROM kurir ORDER BY NamaPerusahaan");
                            if ($r[IdPerusahaan]==0){
                            echo "<option value=0 selected>- Pilih Jasa Pengiriman -</option>"; }
                            while($w=mysql_fetch_array($tampil)){
                            if ($r[IdPerusahaan]==$w[IdPerusahaan]){
                            echo "<option value=$w[IdPerusahaan] selected>$w[NamaPerusahaan]</option>";
                            }
                            else{
                            echo "<option value=$w[IdPerusahaan]>$w[NamaPerusahaan]</option>";
                            }
                        }
                        echo"</select>";
                    ?>
                 </div>
            </div>
            <div class="row" >
                <div class="col-md-5" >
                    <hr style="margin-top: 10px;"/>
                    <input type="submit" class="btn btn-sm btn-danger  pull-right" style="color: #fff;" value="Lanjut Ke Pembayaran"></a>
                    <a href="index.php" class="btn btn-sm btn-danger pull-right" style="margin-right: 10px; color: #fff;">Kembali Belanja</a>
                </form>
            </div>
        </div>
        </div>
    </div>
--------------------------------------------------------------------------------------
act-customer.php
<?php

/**
 * @author lutfi
 * @copyright 2015
 */
include "config/con_db.php";
 mysql_query("insert into customer (NamaLengkap,
                                    Telpon,
                                    Alamat,
                                    Kodepos,
                                    IdKota,
                                    IdPerusahaan)
                            VALUES('$_POST[namalengkap]',
                                   '$_POST[telpon]',
                                   '$_POST[alamat]',
                                   '$_POST[kodepos]',
                                   '$_POST[kota]',
                                   '$_POST[kurir]')");
    header('location:index.php');

?>