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File: daftarpmb.html
<!DOCTYPE HTML> <html> <head> <meta charset="utf-8"> <meta http-equiv="X-UA-Compatible" content="IE=edge"> <title>Akademi Farmasi Bumi Siliwangi</title> <meta name="viewport" content="width=device-width, initial-scale=1"> <meta name="description" content="" /> <meta name="keywords" content="" /> <meta name="author" content="" /> <meta property="og:title" content=""/> <meta property="og:image" content=""/> <meta property="og:url" content=""/> <meta property="og:site_name" content=""/> <meta property="og:description" content=""/> <meta name="twitter:title" content="" /> <meta name="twitter:image" content="" /> <meta name="twitter:url" content="" /> <meta name="twitter:card" content="" /> <link rel="shortcut icon" href="favicon.ico"> <link href="https://fonts.googleapis.com/css?family=Quicksand:300,400,500,700" rel="stylesheet"> <link rel="stylesheet" href="css/animate.css"> <link rel="stylesheet" href="css/icomoon.css"> <link rel="stylesheet" href="css/bootstrap.css"> <link rel="stylesheet" href="css/flexslider.css"> <link rel="stylesheet" href="fonts/flaticon/font/flaticon.css"> <link rel="stylesheet" href="css/owl.carousel.min.css"> <link rel="stylesheet" href="css/owl.theme.default.min.css"> <link rel="stylesheet" href="css/style.css"> <script src="js/modernizr-2.6.2.min.js"></script> <!-- FOR IE9 below --> <!--[if lt IE 9]> <script src="js/respond.min.js"></script> <![endif]--> <script src='https://www.google.com/recaptcha/api.js'></script> </head> <body> <div id="colorlib-page"> <a href="#" class="js-colorlib-nav-toggle colorlib-nav-toggle"><i></i></a> <aside id="colorlib-aside" role="complementary" class="border js-fullheight"> <h1 id="colorlib-logo"><a href="home.html">Akademi Farmasi Bumi Siliwangi</a></h1> <nav id="colorlib-main-menu" role="navigation"> <ul> <li><a href="home.html">Home</a></li> <li><a href="berita.html">Berita</a></li> <li class="colorlib-active"><a href="pmb.html">Penerimaan Mahasiswa Baru</a></li> <li><a href="akademik.html">Akademik</a></li> <li><a href="mahasiswaalumni.html">Mahasiswa dan Alumni</a></li> <li><a href="mou.html">MOU</a></li> <li><a href="tentangakfar.html">Tentang Akfar Bumsil</a></li> <li><a href="contact.html">Kontak</a></li> </ul> </nav> <div class="colorlib-footer"> <ul> <li><a href="#"><i class="icon-facebook2"></i></a></li> <li><a href="#"><i class="icon-twitter2"></i></a></li> <li><a href="#"><i class="icon-instagram"></i></a></li> <li><a href="#"><i class="icon-linkedin2"></i></a></li> </ul> </div> </aside> <div id="colorlib-main"> <div class="colorlib-services"> <div class="colorlib-narrow-content"> <div class="row"> <div class="col-md-6 col-md-offset-3 col-md-pull-3 animate-box" data-animate-effect="fadeInLeft"> <span class="heading-meta">Daftar PMB</span> <h2 class="colorlib-heading">Pendaftaran PMB Akademi Farmasi Bumi Siliwangi</h2> </div> </div> <div class="row row-bottom-padded-md"> <h3>Upload Bukti Pembayaran</h3> <form method="post" action="uploadpmb.php" enctype="multipart/form-data"> <table cellpadding="8"> Data Pribadi <br> <tr> <td>Nama Lengkap (Sesuai Ijazah)</td> <td><input type="text" name="nama"></td> </tr> <tr> <td>Jenis Kelamin </td> <td><input type="radio" name="genre" value="laki">Laki-Laki <br> <input type="radio" name="genre" value="perempuan">Perempuan</td> </tr> <tr> <td>Tempat Lahir </td> <td><input type="text" name="tempatlahir"></td> </tr> <tr> <td>Tanggal Lahir </td> <td><input type="text" name="tgllahir"></td> </tr> <tr> <td>Agama </td> <td><select name="agama"> <option value="islam">Islam</option> <option value="katolik">Katolik</option> <option value="protestan">Protestan</option> <option value="hindu">Hindu</option> <option value="budha">Budha</option> <option value="konghucu">Kong Hu Cu</option> </select></td> </tr> <tr> <td>Tinggi Badan (cm) </td> <td><input type="text" name="tinggi"></td> </tr> <tr> <td>Berat Badan (kg) </td> <td><input type="text" name="berat"></td> </tr> <tr> <td>Nomor KTP </td> <td><input type="text" name="ktp"></td> </tr> <tr> <td>Alamat Lengkap Sesuai KTP </td> <td><input type="text" name="alamat"></td> </tr> <tr> <td>Kota </td> <td><input type="text" name="kota"></td> </tr> <tr> <td>Provinsi </td> <td><input type="text" name="provinsi"></td> </tr> <tr> <td>No. Telepon/HP </td> <td><input type="text" name="hp"></td> </tr> <tr> <td>Email </td> <td><input type="text" name="email"></td> </tr> <tr> <td>Ukuran Jas Almamater </td> <td><select name="jas"> <option value="s">S</option> <option value="m">M</option> <option value="l">L</option> <option value="xl">XL</option> <option value="xxl">XXL</option> </select></td> </tr> <tr> <td>Kelas Diambil </td> <td><input type="radio" name="kelas" value="pagi">Reguler Pagi <br> <input type="radio" name="kelas" value="sore">Reguler Sore</td> </tr> <tr> <td>Program Studi Diambil </td> <td><select name="prodi"> <option value="d4farmasi">----------</option> <option value="d3farmasi">D3 Farmasi</option> </select></td> </tr> </table> <br> <table cellpadding="8"> Data Sekolah <br> <tr> <td>Nama Sekolah Asal</td> <td><input type="text" name="sekolah"></td> </tr> <tr> <td>Kota (Sekolah Asal)</td> <td><input type="text" name="kotasekolah"></td> </tr> <tr> <td>Provinsi (Sekolah Asal)</td> <td><input type="text" name="provinsisekolah"></td> </tr> <tr> <td>Jenis Sekolah</td> <td><select name="jenissekolah"> <option value="sma">SMA</option> <option value="smk">SMK/Kejuruan</option> <option value="keagamaan">Keagamaan</option> </select></td> </tr> <tr> <td>Status Sekolah</td> <td><input type="radio" name="statussekolah" value="negeri">Negeri <br> <input type="radio" name="statussekolah" value="swasta">Swasta</td> </tr> <tr> <td>Jurusan</td> <td><input type="text" name="jurusan"></td> </tr> <tr> <td>Tahun Lulus</td> <td><input type="text" name="tahunlulus"></td> </tr> </table> <br> <table cellpadding="8"> Data Orang Tua <br> <tr> <td>Nama Ayah</td> <td><input type="text" name="ayah"></td> </tr> <tr> <td>Nama Ibu</td> <td><input type="text" name="ibu"></td> </tr> <tr> <td>Pekerjaan Ayah</td> <td><input type="text" name="kerjaayah"></td> </tr> <tr> <td>Pekerjaan Ibu</td> <td><input type="text" name="kerjaibu"></td> </tr> <tr> <td>Penghasilan Orang Tua</td> <td><select name="penghasilan"> <option value="1jt">Kurang Dari Rp 1.000.000 per bulan</option> <option value="3jt">Rp 1.000.000 - Rp 3.000.000 per bulan</option> <option value="5jt">Rp 3.000.000 - Rp 5.000.000 per bulan</option> <option value="6jt">Di atas Rp 5.000.000 per bulan</option> </select></td> </tr> <tr> <td>Sumbangan Sukarela (Min 1.500.000 kelipatan 1.000.000)</td> <td><input type="text" name="sumbangan"></td> </tr> </table> <br> <table cellpadding="8"> Data Rekomendasi <br> <tr> <td>Informasi Pendaftaran</td> <td><select name="infodaftar"> <option value="brosur">Brosur</option> <option value="spanduk">Spanduk</option> <option value="internet">Internet</option> <option value="iklan">Iklan</option> <option value="keluarga">Keluarga/Kerabat</option> <option value="lainnya">Pihak Lainnya</option> </select></td> </tr> <tr> <td>Tuliskan Nama Orang Yang Merekomendasikan (Jika Ada)</td> <td><input type="text" name="namarekomendasi"></td> </tr> </table> <br> <table cellpadding="8"> Upload <br> <tr> <td>Upload Scan Surat Keterangan Lulus/Legalisir Ijazah</td> <td><input type="file" name="ijazah"></td> </tr> <tr> <td>Upload Scan SKHUN Legalisir</td> <td><input type="file" name="skhun"></td> </tr> <tr> <td>Pas Foto Ukuran 3x4</td> <td><input type="file" name="foto3x4"></td> </tr> <tr> <td>Pas Foto Ukuran 2x3</td> <td><input type="file" name="foto2x3"></td> </tr> <tr> <td>Surat Keterangan Telah Bekerja (Bagi Yang Mengambil Kelas Reg Sore)</td> <td><input type="file" name="skkelassore"></td> </tr> <tr> <td> Bukti Transfer Uang Pendaftaran Rp 200.000,00</td> <td><input type="file" name="buktiuangpendaftaran"></td> </tr> <tr> <td> Scan Surat Keterangan Sehat</td> <td><input type="file" name="suratsehat"></td> </tr> <tr> <td> Surat Keterangan Tidak Buta Warna</td> <td><input type="file" name="surattidakbutawarna"></td> </tr> </table> <br> <table cellpadding="8"> <div class="g-recaptcha" data-sitekey="6LcxSIkUAAAAALUMm2ZCCGyv-OC-MRi3khb-TuS4"></div> </table> <hr> <input type="submit" name="simpan" value="simpan"> <a href="index.php"><input type="button" value="Batal"> </a> </form> </div> </div> </div> <div id="get-in-touch" class="colorlib-bg-color"> <div class="colorlib-narrow-content"> <div class="row"> <div class="col-md-6 animate-box" data-animate-effect="fadeInLeft"> <a href="pmb.html"> <img src="images/icon/1486486321-arrow-96px.ico" alt=""/> </a> </div> </div> <div class="row"> <div class="col-md-6 animate-box" data-animate-effect="fadeInLeft"> <h2>Kembali</h2> </div> </div> </div> </div> </div> <script src="js/jquery.min.js"></script> <script src="js/jquery.easing.1.3.js"></script> <script src="js/bootstrap.min.js"></script> <script 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