<html>
<head>
<title>Formulir Pendaftaran OP</title>
</head>
<body alink="black" link="black" vlink="black">
<h3 align="center"><u>Formulir Pendaftaran OP</u></h3>
<form action="http://pub37.bravenet.com/emailfwd/senddata.php"
method="post" enctype="multipart/form-data">
<input type="hidden" name="usernum" value="3143298488" />
<input type="hidden" name="cpv" value="1" />
<table border="0">
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Nama Lengkap
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="name" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Nama panggilan
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="aliase" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Jenis Kelamin
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="radio" name="gender" value="pria"><font face="Verdana" size="2">Male
<input type="radio" name="gender" value="wanita"><font face="Verdana" size="2">Female
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">E-Mail
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="imel" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Homepage (*)
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="homepage" value="http://" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Tanggal Lahir
</td>
<td><font face="verdana" size="2">:</td>
<td>
<select name="bdate">
<option value="1"><font face="Verdana" size="2">01
<option value="2"><font face="Verdana" size="2">02
<option value="3"><font face="Verdana" size="2">03
<option value="4"><font face="Verdana" size="2">04
<option value="5"><font face="Verdana" size="2">05
<option value="6"><font face="Verdana" size="2">06
<option value="7"><font face="Verdana" size="2">07
<option value="8"><font face="Verdana" size="2">08
<option value="9"><font face="Verdana" size="2">09
<option value="10"><font face="Verdana" size="2">10
<option value="11"><font face="Verdana" size="2">11
<option value="12"><font face="Verdana" size="2">12
<option value="13"><font face="Verdana" size="2">13
<option value="14"><font face="Verdana" size="2">14
<option value="15"><font face="Verdana" size="2">15
<option value="16"><font face="Verdana" size="2">16
<option value="17"><font face="Verdana" size="2">17
<option value="18"><font face="Verdana" size="2">18
<option value="19"><font face="Verdana" size="2">19
<option value="20"><font face="Verdana" size="2">20
<option value="21"><font face="Verdana" size="2">21
<option value="22"><font face="Verdana" size="2">22
<option value="23"><font face="Verdana" size="2">23
<option value="24"><font face="Verdana" size="2">24
<option value="25"><font face="Verdana" size="2">25
<option value="26"><font face="Verdana" size="2">26
<option value="27"><font face="Verdana" size="2">27
<option value="28"><font face="Verdana" size="2">28
<option value="29"><font face="Verdana" size="2">29
<option value="30"><font face="Verdana" size="2">30
<option value="31"><font face="Verdana" size="2">31
</select>
<select name="bmonth">
<option value="1"><font face="Verdana" size="2">Jan
<option value="2"><font face="Verdana" size="2">Feb
<option value="3"><font face="Verdana" size="2">Mar
<option value="4"><font face="Verdana" size="2">Apr
<option value="5"><font face="Verdana" size="2">Mei
<option value="6"><font face="Verdana" size="2">Jun
<option value="7"><font face="Verdana" size="2">Jul
<option value="8"><font face="Verdana" size="2">Aug
<option value="9"><font face="Verdana" size="2">Sep
<option value="10"><font face="Verdana" size="2">Okt
<option value="11"><font face="Verdana" size="2">Nov
<option value="12"><font face="Verdana" size="2">Des
</select>
<input type="text" name="byear" maxlength="4" value="19"size="4">
<td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Asal dari Kota
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="city" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Sekarang berada di Negara
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="country" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">di Kota
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="ncity" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Nickname yg sering di pakai
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="nick" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Nickname Lain
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="othernick" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">ICQ (*)
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="icq" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">Yahoo Messenger (*)
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="yim" size="25">
</td>
</tr>
<tr>
<td> </td>
<td>
<font face="verdana" size="2">MSN (*)
</td>
<td><font face="verdana" size="2">:</td>
<td>
<input type="text" name="msn" size="25">
</td>
</tr>
<tr>
<td colspan="4"><hr></td>
</tr>
<tr>
<td> </td>
<td colspan="3">
<font face="verdana" size="2">Pada biasanya berapa hari dalam 1 minggu anda ber-IRC?
</td>
</tr>
<tr>
<td> </td>
<td colspan="3">
<input type="text" name="dayperweek" size="35">
</td>
</tr>
<tr>
<td> </td>
<td colspan="3">
<font face="verdana" size="2">Pada biasanya berapa jam per hari anda ber-IRC?
</td>
</tr>
<tr>
<td> </td>
<td colspan="3">
<input type="text" name="timeperday" size="35">
</td>
</tr>
<tr>
<td colspan="4"><hr></td>
</tr>
<tr>
<td> </td>
<td colspan="3">
<font color="red" face="verdana" size="2"><b>Selain pertanyaan yang mempunyai tanda (*), semua pertanyaan harus diisi. Klik "Daftar" apabila semua pertanyaan telah terisi. Dan untuk melihat aturan-aturan klik</font> <a href="http://www.angelfire.com/art2/g30/syarat2">di sini</a><br><br>
</td>
</tr>
<tr>
<td colspan="4" align="center">
<input type="submit" name="submit" value=" Daftar ">
<input type="reset" name="reset" value=" Ulang ">
</td>
</tr>
</table>
</form>
<br><br>
<font face="verdana" size="2"><b><a href="http://www.doiku.cjb.net">::H o m e::</a></b></font>
</body>
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<p>
</body>
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