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- <!DOCTYPE html>
- <html>
- <head>
- <meta charset="utf-8">
- <meta http-equiv="X-UA-Compatible" content="IE=edge">
- <title>HTML - Form</title>
- <meta name="description" content="">
- <meta name="viewport" content="width=device-width, initial-scale=1">
- </head>
- <body>
- <h1>Formulir Pendaftaran</h1>
- <form action="" method="post">
- <fieldset>
- <legend>Biodata Diri</legend>
- <p>Masukkan data di bawah ini dengan benar!</p>
- <table>
- <tr>
- <td>
- <label for="fname">Nama Depan</label>
- </td>
- <td>
- <input type="text" name="fname" id="fname">
- </td>
- </tr>
- <tr>
- <td>
- <label for="lname">Nama Belakang</label>
- </td>
- <td>
- <input type="text" name="lname" id="lname">
- </td>
- </tr>
- <tr>
- <td>
- <label>Jenis Kelamin</label>
- </td>
- <td>
- <input type="radio" name="jk" id="laki" value="laki">
- <label for="laki">Laki-laki</label>
- <br>
- <input type="radio" name="jk" id="perempuan" value="perempuan">
- <label for="perempuan">Perempuan</label>
- </td>
- </tr>
- <tr>
- <td>
- <label for="pob">Tempat Lahir</label>
- </td>
- <td>
- <input type="text" name="pob" id="pob">
- </td>
- </tr>
- <tr>
- <td>
- <label for="dob">Tanggal Lahir</label>
- </td>
- <td>
- <input type="date" name="dob" id="dob">
- </td>
- </tr>
- </table>
- </fieldset>
- <br>
- <fieldset>
- <legend>Alamat Lengkap</legend>
- <table>
- <tr>
- <td>
- <label for="provinsi">Provinsi</label>
- </td>
- <td>
- <select name="provinsi" id="provinsi">
- <option value="0">-Pilih Provinsi-</option>
- <option value="1">DKI Jakarta</option>
- <option value="2">Jawa Barat</option>
- <option value="3">Banten</option>
- <option value="4">Jawa Tengah</option>
- </select>
- </td>
- </tr>
- <tr>
- <td>
- <label for="kota">Kota</label>
- </td>
- <td>
- <select name="kota" id="kota">
- <option value="0">-Pilih Kota-</option>
- <option value="1">Jakarta Utara</option>
- <option value="2">Jakarta Pusat</option>
- <option value="3">Jakarta Barat</option>
- <option value="4">Jakarta Timur</option>
- <option value="5">Jakarta Selatan</option>
- </select>
- </td>
- </tr>
- <tr>
- <td>
- <label for="kecamatan">Kecamatan</label>
- </td>
- <td>
- <select name="kecamatan" id="kecamatan">
- <option value="0">-Pilih Kecamatan-</option>
- </select>
- </td>
- </tr>
- <tr>
- <td>
- <label for="kelurahan">Desa / Kelurahan</label>
- </td>
- <td>
- <select name="kelurahan" id="kelurahan">
- <option value="0">-Pilih Desa / Kelurahan-</option>
- </select>
- </td>
- </tr>
- <tr>
- <td>
- <label for="alamat">Alamat</label>
- </td>
- <td>
- <textarea name="alamat" id="alamat" cols="25" rows="10"></textarea>
- </td>
- </tr>
- </table>
- </fieldset>
- <br>
- <fieldset>
- <legend>Akun</legend>
- <table>
- <tr>
- <td>
- <label for="email">Email</label>
- </td>
- <td>
- <input type="email" id="email" name="email">
- </td>
- </tr>
- <tr>
- <td>
- <label for="username">Username</label>
- </td>
- <td>
- <input type="text" id="username" name="username" maxlength="10">
- </td>
- </tr>
- <tr>
- <td>
- <label for="pass1">Password</label>
- </td>
- <td>
- <input type="password" id="pass1" name="pass1">
- </td>
- </tr>
- <tr>
- <td>
- <label for="pass2">Konfirmasi Password</label>
- </td>
- <td>
- <input type="password" id="pass2" name="pass2">
- </td>
- </tr>
- </table>
- </fieldset>
- <br>
- <fieldset>
- <legend>Syarat dan ketentuan</legend>
- <p>Dengan memilih "Setuju", anda sudah mengikuti <a href="#">Syarat dan ketentuan</a>yang berlaku</p>
- <input type="checkbox" name="setuju" id="setuju">
- <label for="setuju">Setuju</label>
- <br><br>
- <input type="submit" value="Daftar"> <input type="reset" value="Reset">
- </fieldset>
- </form>
- </body>
- </html>
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