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HamdanNur

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HamdanNur
Jan 4th, 2018
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  1. <!DOCTYPE html>
  2. <html lang="en">
  3. <head>
  4. <title>Bootstrap Example</title>
  5. <meta charset="utf-8">
  6. <meta name="viewport" content="width=device-width, initial-scale=1">
  7. <link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/css/bootstrap.min.css">
  8. <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script>
  9. <script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/js/bootstrap.min.js"></script>
  10.  
  11. </head>
  12. <body>
  13. <h2>Formulir Pendaftaran Mahasiswa Baru</h2>
  14. <hr/>
  15. <form class="form-horizontal" action="index.php?hal=simpan" method="post">
  16. <h4 class="bg-info">Informasi Akun Login</h4>
  17. <div class="form-group">
  18. <label class="control-label col-sm-2">Email:</label>
  19. <div class="col-sm-10">
  20. <input type="email" class="form-control" name="email" required>
  21. </div>
  22. </div>
  23. <div class="form-group">
  24. <label class="control-label col-sm-2">Password:</label>
  25. <div class="col-sm-10">
  26. <input type="text" class="form-control" name="password" required>
  27. </div>
  28. </div>
  29.  
  30. <hr/>
  31.  
  32. <h4 class="bg-success">Informasi Program Studi</h4>
  33. <div class="form-group">
  34. <label class="control-label col-sm-2">Pilihan Jurusan:</label>
  35. <div class="col-sm-10">
  36. <select required class="form-control" id="prodi" name="prodi" >
  37. <option></option>
  38. <option value="S1 - Teknik Informatika">S1 - Teknik Informatika</option>
  39. <option value="S1 - Sistem Informasi">S1 - Sistem Informasi</option>
  40. <option value="D3 - Manajemen Informatika">D3 - Manajemen Informatika</option>
  41. </select>
  42. </div>
  43. </div>
  44.  
  45. <hr/>
  46.  
  47. <h4 class="bg-info">Informasi Utama</h4>
  48. <div class="form-group">
  49. <label class="control-label col-sm-2" for="nama">Nama Lengkap:</label>
  50. <div class="col-sm-10">
  51. <input type="text" class="form-control" id="nama" name="nama_lengkap" required>
  52. </div>
  53. </div>
  54. <div class="form-group">
  55. <label class="control-label col-sm-2" for="tempat_lahir">Tempat Lahir:</label>
  56. <div class="col-sm-10">
  57. <input type="text" class="form-control" id="tempat_lahir" name="tempat_lahir" required>
  58. </div>
  59. </div>
  60. <div class="form-group">
  61. <label class="control-label col-sm-2" for="tgl_lahir">Tanggal Lahir:</label>
  62. <div class="col-sm-10">
  63. <input type="date" class="form-control" id="tgl_lahir" placeholder="Tanggal kelahiran" name="tgl_lahir" value="<?php echo date('d-m-Y'); ?>" />
  64. </div>
  65. </div>
  66. <div class="form-group">
  67. <label class="control-label col-sm-2" for="gender">Jenis Kelamin:</label>
  68. <div class="col-sm-10">
  69. <label class="radio-inline"><input type="radio" name="gender" value="Laki-laki">Laki-laki</label>
  70. <label class="radio-inline"><input type="radio" name="gender" value="Perempuan">Perempuan</label>
  71. </div>
  72. </div>
  73. <div class="form-group">
  74. <label class="control-label col-sm-2" for="alamat_lengkap">Alamat Lengkap</label>
  75. <div class="col-sm-10">
  76. <textarea class="form-control" rows="3" name="alamat_lengkap"></textarea>
  77.  
  78. </div>
  79. </div>
  80. <div class="form-group">
  81. <label class="control-label col-sm-2" for="agama">Agama:</label>
  82. <div class="col-sm-10">
  83. <select class="form-control" id="agama" name="agama">
  84. <option>Pilih</option>
  85. <option value="Islam">Islam</option>
  86. <option value="Kristen Protestan">Kristen Protestan</option>
  87. <option value="Katolik">Katolik</option>
  88. <option value="Hindu">Hindu</option>
  89. <option value="Buddha">Buddha</option>
  90. <option value="Kong Hu Cu">Kong Hu Cu</option>
  91. </select>
  92. </div>
  93. </div>
  94.  
  95. <hr/>
  96.  
  97. <h4 class="bg-warning">Informasi Orang Tua</h4>
  98. <div class="form-group">
  99. <label class="control-label col-sm-2">Nama Ayah:</label>
  100. <div class="col-sm-10">
  101. <input type="text" class="form-control" name="nama_ayah" required>
  102. </div>
  103. </div>
  104. <div class="form-group">
  105. <label class="control-label col-sm-2">Nama Ibu:</label>
  106. <div class="col-sm-10">
  107. <input type="text" class="form-control" name="nama_ibu" required>
  108. </div>
  109. </div>
  110. <div class="form-group">
  111. <label class="control-label col-sm-2">Alamat Orang Tua:</label>
  112. <div class="col-sm-10">
  113. <textarea class="form-control" rows="3" id="comment" name="alamat_ortu" required></textarea>
  114. </div>
  115. </div>
  116. <div class="form-group">
  117. <label class="control-label col-sm-2" for="pekerjaan_ayah">Pekerjaan Ayah:</label>
  118. <div class="col-sm-10">
  119. <input type="text" class="form-control" id="pekerjaan_ayah" name="pekerjaan_ayah" required>
  120. </div>
  121. </div>
  122. <div class="form-group">
  123. <label class="control-label col-sm-2" for="pekerjaan_ibu">Pekerjaan Ibu:</label>
  124. <div class="col-sm-10">
  125. <input type="text" class="form-control" id="pekerjaan_ibu" name="pekerjaan_ibu" required>
  126. </div>
  127. </div>
  128.  
  129. <input type="hidden" class="form-control" name="status" value="Tahap Seleksi">
  130.  
  131. <div class="form-group">
  132. <div class="col-sm-offset-2 col-sm-10">
  133. <button type="submit" class="btn btn-success" name="registrasi">Registrasi</button>
  134. <button type="reset" class="btn btn-danger">Hapus</button>
  135. </div>
  136. </div>
  137. </form>
  138. </body>
  139. </html>
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