<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Form Name</legend> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="selectbasic">Pilihan Premi</label> <div class="col-md-4"> <select id="selectbasic" name="selectbasic" class="form-control"> <option value="1">Rp. 350.000,-</option> <option value="2">Rp. 700.000,-</option> <option value="3">Rp. 1.000.000,-</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="namasponsor">Nama Sponsor *</label> <div class="col-md-4"> <input id="namasponsor" name="namasponsor" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="noidsponsor">No. ID Sponsor *</label> <div class="col-md-4"> <input id="noidsponsor" name="noidsponsor" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="namaupline">Nama Upline *</label> <div class="col-md-4"> <input id="namaupline" name="namaupline" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="noidupline">No. ID Upline *</label> <div class="col-md-4"> <input id="noidupline" name="noidupline" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="namalengkap">Nama Lengkap (Sesuai Identitas) *</label> <div class="col-md-5"> <input id="namalengkap" name="namalengkap" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="alamat">Alamat Surat Menyurat *</label> <div class="col-md-5"> <input id="alamat" name="alamat" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="rt">RT *</label> <div class="col-md-2"> <input id="rt" name="rt" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="rw">RW *</label> <div class="col-md-2"> <input id="rw" name="rw" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="kelurahan">Kelurahan *</label> <div class="col-md-4"> <input id="kelurahan" name="kelurahan" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="kecamatan">Kecamatan *</label> <div class="col-md-4"> <input id="kecamatan" name="kecamatan" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="kota">Kota / Kabupaten *</label> <div class="col-md-4"> <input id="kota" name="kota" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="provinsi">Provinsi *</label> <div class="col-md-4"> <input id="provinsi" name="provinsi" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="kodepos">Kode Pos *</label> <div class="col-md-2"> <input id="kodepos" name="kodepos" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="tempatlahir">Tempat Lahir *</label> <div class="col-md-4"> <input id="tempatlahir" name="tempatlahir" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="tanggallahir">Tanggal Lahir *</label> <div class="col-md-4"> <input id="tanggallahir" name="tanggallahir" placeholder="HH/BB/TTTT" class="form-control input-md" required="" type="text"> <span class="help-block">Contoh: 29/01/1985</span> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="agama">Agama *</label> <div class="col-md-4"> <select id="agama" name="agama" class="form-control"> <option value="0">Pilih</option> <option value="1">Islam</option> <option value="2">Kristen</option> <option value="3">Katolik</option> <option value="4">Hindu</option> <option value="5">Budha</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="jeniskelamin">Jenis Kelamin *</label> <div class="col-md-4"> <select id="jeniskelamin" name="jeniskelamin" class="form-control"> <option value="0">Pilih</option> <option value="1">Laki-laki</option> <option value="2">Perempuan</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="nohp">No. HP *</label> <div class="col-md-4"> <input id="nohp" name="nohp" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="identitas">Identitas *</label> <div class="col-md-4"> <select id="identitas" name="identitas" class="form-control"> <option value="0">Pilih</option> <option value="1">KTP</option> <option value="2">SIM</option> <option value="3">PASPOR</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="noidentitas">No. Identitas *</label> <div class="col-md-4"> <input id="noidentitas" name="noidentitas" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="email">Email *</label> <div class="col-md-4"> <input id="email" name="email" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="statuspajak">Status Pajak *</label> <div class="col-md-4"> <select id="statuspajak" name="statuspajak" class="form-control"> <option value="0">Pilih</option> <option value="1">Tidak Kawin</option> <option value="2">Kawin</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="nonpwp">No. NPWP *</label> <div class="col-md-4"> <input id="nonpwp" name="nonpwp" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="jumlahtanggungan">Jumlah Tanggungan *</label> <div class="col-md-4"> <input id="jumlahtanggungan" name="jumlahtanggungan" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="pekerjaan">Pekerjaan *</label> <div class="col-md-4"> <input id="pekerjaan" name="pekerjaan" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="jabatan">Jabatan *</label> <div class="col-md-4"> <input id="jabatan" name="jabatan" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="penghasilan">Penghasilan Per Tahun</label> <div class="col-md-4"> <select id="penghasilan" name="penghasilan" class="form-control"> <option value="0">Pilih</option> <option value="1">< 100 JT</option> <option value="2">100 - 500 JT</option> <option value="3">500 - 1 M</option> <option value="4">> 1 M</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="tinggi">Tinggi Badan (cm) *</label> <div class="col-md-2"> <input id="tinggi" name="tinggi" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="berat">Berat Badan (kg) *</label> <div class="col-md-2"> <input id="berat" name="berat" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="namabank">Nama Bank *</label> <div class="col-md-4"> <input id="namabank" name="namabank" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="nomorrek">Nomor Rekening *</label> <div class="col-md-4"> <input id="nomorrek" name="nomorrek" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="cabangbank">Cabang Bank *</label> <div class="col-md-4"> <input id="cabangbank" name="cabangbank" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="namapemilikrek">Nama Pemilik Rekening *</label> <div class="col-md-4"> <input id="namapemilikrek" name="namapemilikrek" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="namalengkapahliwaris">Nama Lengkap Ahli Waris *</label> <div class="col-md-4"> <input id="namalengkapahliwaris" name="namalengkapahliwaris" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="jeniskelaminahliwaris">Jenis Kelamin *</label> <div class="col-md-4"> <select id="jeniskelaminahliwaris" name="jeniskelaminahliwaris" class="form-control"> <option value="0">Pilih</option> <option value="1">Laki-laki</option> <option value="2">Perempuan</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="tempatlahirahliwaris">Tempat Lahir *</label> <div class="col-md-4"> <input id="tempatlahirahliwaris" name="tempatlahirahliwaris" placeholder="Jawaban Anda" class="form-control input-md" required="" type="text"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="tanggallahirahliwaris">Tanggal Lahir *</label> <div class="col-md-4"> <input id="tanggallahirahliwaris" name="tanggallahirahliwaris" placeholder="HH/BB/TTTT" class="form-control input-md" required="" type="text"> <span class="help-block">Contoh: 29/01/1985</span> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="hubungandengantertanggung">Hubungan Dengan tertanggung *</label> <div class="col-md-4"> <select id="hubungandengantertanggung" name="hubungandengantertanggung" class="form-control"> <option value="0">Pilih</option> <option value="1">Anak</option> <option value="2">Ayah</option> <option value="3">Ibu</option> <option value="4">Istri</option> <option value="5">Suami</option> <option value="6">Saudara Perempuan</option> <option value="7">Saudara Laki-laki</option> <option value="8">Kakak Kandung</option> <option value="9">Adik Kandung</option> <option value="10">Tertanggung</option> <option value="11">Diri Sendiri</option> </select> </div> </div> <!-- File Button --> <div class="form-group"> <label class="col-md-4 control-label" for="unggahidentitas">File Identitas *</label> <div class="col-md-4"> <input id="unggahidentitas" name="unggahidentitas" class="input-file" type="file"> </div> </div> <!-- File Button --> <div class="form-group"> <label class="col-md-4 control-label" for="tandatangan">Tanda Tangan *</label> <div class="col-md-4"> <input id="tandatangan" name="tandatangan" class="input-file" type="file"> </div> </div> <!-- File Button --> <div class="form-group"> <label class="col-md-4 control-label" for="npwp">NPWP</label> <div class="col-md-4"> <input id="npwp" name="npwp" class="input-file" type="file"> </div> </div> <!-- File Button --> <div class="form-group"> <label class="col-md-4 control-label" for="halamandepanbukutabungan">Halaman Depan Buku Tabungan</label> <div class="col-md-4"> <input id="halamandepanbukutabungan" name="halamandepanbukutabungan" class="input-file" type="file"> </div> </div> <!-- Button --> <div class="form-group"> <label class="col-md-4 control-label" for="kirim"></label> <div class="col-md-4"> <button id="kirim" name="kirim" class="btn btn-primary">Kirim</button> </div> </div> </fieldset> </form>