<html>
<head>
<title>farah web</title>
</head>
<form>
<body bgcolor=black>
<table border=1>
<tr><td width="1000" height="150" align="center" background="Itachi Uchiha.jpg">
<font size=5 color="blue"><b>Pendaftaran Biasa</b></font>
</td></tr>
</table>
<br><br>
<TABLE BORDER=0>
<TR><TD>First Name :</TD><TD><INPUT TYPE=TEXT NAME=nama SIZE=20></TD></TR>
<TR><TD>Last Name :</TD><TD><INPUT TYPE=TEXT NAME=NAMA SIZE=20></TD></TR>
<TR><TD>Alamat :</TD><TD><INPUT TYPE=TEXT NAME=ALAMAT SIZE=20></TD></TR>
<TR><TD>Telpon :</TD><TD><INPUT TYPE=TEXT \ NAME=TELPON SIZE=20></TD></TR>
<TR><TD>Code Post :</TD><TD><INPUT TYPE=TEXT NAME=code post SIZE=20></TD></TR>
<TR><TD>Password :</TD><TD><INPUT TYPE=password NAME=password SIZE=20></TD></TR>
<TR><TD>Re-Password :</TD><TD><INPUT TYPE=password NAME=password SIZE=20></TD></TR>
<TR><TD>E-mail :</TD><TD><INPUT TYPE=TEXT NAME=E-mail SIZE=20>@gibol.com</TD></TR>
<TR><TD>User ID :</TD><TD><INPUT TYPE=TEXT NAME=Nama SIZE=20></TD></TR>
<TR><TD>Gender :</TD><TD><INPUT TYPE=RADIO NAME=GENDER>Male</TD></TR>
<TR><TD></TD><TD><INPUT TYPE=RADIO NAME=GENDER>Female</TD></TR>
<TR><TD>Tanggal :</TD><TD><SELECT NAME=Tanggal>
<OPTION VALUE="........"> ........
<OPTION VALUE="1">1
<OPTION VALUE="2">2
<OPTION VALUE="3">3
<OPTION VALUE="4">4
<OPTION VALUE="5">5
<OPTION VALUE="6">6
<OPTION VALUE="7">7
<OPTION VALUE="8">8
<OPTION VALUE="9">9
<OPTION VALUE="10">10
<OPTION VALUE="11">11
<OPTION VALUE="12">12
<OPTION VALUE="13">13
<OPTION VALUE="14">14
<OPTION VALUE="15">15
<OPTION VALUE="16">16
<OPTION VALUE="17">17
<OPTION VALUE="18">18
<OPTION VALUE="19">19
<OPTION VALUE="20">20
<OPTION VALUE="21">21
<OPTION VALUE="22">22
<OPTION VALUE="23">23
<OPTION VALUE="24">24
<OPTION VALUE="25">25
<OPTION VALUE="26">26
<OPTION VALUE="27">27
<OPTION VALUE="28">28
<OPTION VALUE="29">29
<OPTION VALUE="30">30
<OPTION VALUE="31">31</td>
<td>Bulan :<select name="bulan">
<OPTION selected VALUE="........"> ........
<OPTION VALUE="Januari">Januari
<OPTION VALUE="Pebruari">Pebruari
<OPTION VALUE="Maret">Maret
<OPTION VALUE="April">April
<OPTION VALUE="Mei">Mei
<OPTION VALUE="Juni">Juni
<OPTION VALUE="Juli">Juli
<OPTION VALUE="Agustus">Agustus
<OPTION VALUE="September">September
<OPTION VALUE="Oktober">Oktober
<OPTION VALUE="November">November
<OPTION VALUE="Desember">Desember</td>
<td>Tahun :</td>
<td><INPUT TYPE=TEXT NAMe=tahun SIZE=6></td>
</select></td></tr>
<TR><TD>Komentar :</TD>
<TD><TEXTAREA NAME=MASUKAN ROWS=6 COLS=35></TEXTAREA></TD></TR>
<TR><TD>Foto :</TD>
<TD><INPUT type=FILE NAME=Foto SIZE=40></TEXTAREA></TD></TR>
</TABLE><br><br>
<Table>
<TR><TD></TD><TD><INPUT TYPE=CHECKBOX NAME=Setuju>Anda yakin dengan apa yang anda pilih</TD></TR>
</table><br><br><br><br>
<table>
<TR><TD></TD><TD><INPUT TYPE=SUBMIT NAME=KIRIM VALUE=Submit>
<INPUT TYPE=RESET NAME=BATAL VALUE=Batalkan></td></tr>
</table>
</form>
</body>
</html>
