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    <meta name="viewport" content="width=device-width, initial-scale=1.0">
    <link rel="stylesheet" href="style.css">
    <script src="https://kit.fontawesome.com/5d2ca4097f.js" crossorigin="anonymous"></script>
    <script src="script.js"></script>
    <title>Form</title>
</head>
<body>
        <div class="container">

            <div class="form">
                <div class="header">
                    <h1>FORMULIR REGISTRASI</h1>
                    <h2><br>PESERTA</p>
                </div>
                <div class="form-input">
                    <label>Nama Lengkap & Gelar</label>
                    <input type="text" name="" id="name" required/>
                </div>
                <div class="form-input">
                    <label>Asal Instansi / Kota</label>
                    <input type="text" name="" id="kota" required/>
                </div>
                <div class="form-input">
                    <label>Alamat</label>
                    <input type="text" name="" id="alamat" required/>
                </div>
                <div class="form-input">
                    <label>Kode Pos</label>
                    <input type="text" name="" id="kode" required/>
                </div>
                <!-- <div class="form-input">
                    <label>Provinsi</label>
                    <input type="text" name="provinsi" id="alamat" required/>
                </div> -->
                <div class="form-input">
                    <label>Provinsi</label>
                    <select name="">
                     <option value="DKI JAKARTA">DKI JAKARTA</option>
                     <option value="Banten">Banten</option>
                     <option value="Jawa Barat">Jawa Barat</option>
                     <option value="Jawa Tengah">Jawa Tengah</option>
                     <option value="Jawa Timur">Jawa Timur</option>
                     <option value="lainnya">LAINNYA</option>
                    </select>
                </div>
                <div class="form-input">
                    <label>Telepon / Handphone</label>
                    <input type="text" name="" id="HP" required/>
                </div>
                <div class="form-input">
                    <label>Email</label>
                    <input type="text" name="" id="email" required/>
                </div>
                <div class="form-input">
                    <label>Sponsor</label>
                    <input type="text" name="" id="sponsor" required/>
                </div>
                <div class="form-input">
                    <label>Nama Perusahaan</label>
                    <input type="text" name="" id="namaPerusahaan" required/>
                </div>
                <div class="form-input">
                    <label>Alamat Perusahaan</label>
                    <input type="text" name="" id="alamatPerusahaan" required/>
                </div>
                <div class="form-input">
                    <label>Nama Kontak Personal</label>
                    <input type="text" name="" id="namaKontakPersonal" required/>
                </div>
                <div class="form-input">
                    <label>Telepon Personal</label>
                    <input type="text" name="" id="teleponPersonal" required/>
                </div>
                <div class="form-input">
                    <label>Email Perusahaan</label>
                    <input type="text" name="" id="emailPerusahaan" required/>
                </div>
                <div class="input-field button">
                    <input type="button" name="" value="Complete Registration" onclick="registration()">
                </div>

                <div class="messages">
                    <h1>PESAN</h1>
                    <p>Kontribusi peserta Rp. 2.500.000,-(Dua Juta Lima Ratus Ribu Rupiah) belum termasuk
                        penginapan dan akomodasi
                        <br>
                        <br>
                        Konfirmasi Kepesertaan :
                        <br>
                        <br>
                        *Sebelum 15 Januari 2012 : Rp. 2.500.000,-
                        <br>
                        *Sesudah 15 Januari 2012 : Rp. 2.750.000,-
                        <br>
                        *On Site                 : Rp. 3.000.000,-
                        <br>
                        <br>
                        Pembatalan Pendaftaran: * Sebelum H-5 uang dikembalikan 50%
                        <br>
                        &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp
                        &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp
                        &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp
                        * sesudah H-5 uang tidak dapat dikembalikan
                        <br>
                        <br>
                        Akomodasi PEnginapan peserta, harga kamar kelas standar berkisar antara
                        Rp. 250.000,- - Rp.300.000,-*)
                        <br><br>
                    </p>
                    <h3>Pendaftaran via transfer Bank ke :
                        <br>
                        Nama Bank : Bannk BCA KCU Cirebon
                        <br>
                        No. Rekening : 1341015478
                        <br>
                        Atas Nama : Junaedi, S.kep
                        <br>
                    </h3>
                </div>

                <div class="box">
                    <p>Bukti transfer mogon dikirim ke alamat Sekretariat Panitia UPTD Puskesmas Sitopeng
                        <br>
                        Jl.Sekarsari No. 1 Argasunya Harja mukti Kota Cirebon
                        <br>
                        atau kirim ke email : [email protected]
                        <br>
                        konfirmasi setelah transfer ke 2818232869
                    </p>
                </div>
            </div>
        </div>
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