Struk Telkom

<!DOCTYPE html>
<head>
<title>Cetak Struk Telkom</title>
<link rel="stylesheet" type="text/css" href="//code.jquery.com/ui/1.9.2/themes/base/jquery-ui.css" />
<script src="//ajax.googleapis.com/ajax/libs/jquery/1.8.3/jquery.min.js"></script>
<script src="//code.jquery.com/ui/1.9.2/jquery-ui.min.js"></script>
<script>
$(function(){
$("#datepicker").datepicker();
})
</script>
<style>body{font-family:arial;font-size:14px;color:#333;background:#eee}form{width:350px;margin:20px auto}input{padding:3px 4px;font-family:tahoma;font-size:14px}input[type="text"]{width:200px}input[type="submit"]{padding:6px 18px;font-weight:bold;cursor:pointer}#nsm{font-size:18px;font-weight:bold}h1{margin:0;padding:2px 0;font-size:22px}</style>
</head>
<body>
<form action="https://202.52.50.30/strukppob/view.php" method="post"><br />
<br /><br />
<h1>Cetak Struk Pembayaran TELKOM</h1><br />
<table>
    <tr>
        <td>Tanggal</td>
        <td><input type="text" id="datepicker" name="datepicker" placeholder="mm/dd/yyyy" value="<?php echo date('m/d/Y') ?>" required /></td>
    </tr>
    <tr>
        <td>ID Pelanggan</td>
        <td><input type="text" id="nsm" name="tujuan" placeholder="ID Pelanggan" value="" required /></td>
    </tr>
    <tr>
        <td>&nbsp;</td>
        <td><input type="submit" value="Cetak" /></td>
    </tr>
</table>
<input type="hidden" name="noreff" value="123" />
<input type="hidden" name="jenis" value="2" />
</form>
</body>
</html>