MPP BIAK NUMFOR

 <form action="//submit.form" id="NewsletterSubscription100" method="post" onsubmit="return ValidateForm(this);">

<script type="text/javascript">

function ValidateForm(frm) {

if (frm.Name.value == "") { alert('Mohon isi nama anda.'); frm.Name.focus(); return false; }

if (frm.Birthplace.value == "") { alert('Mohon isi tempat lahir anda.'); frm.Birthplace.focus(); return false; }

if (frm.Birthdate.value == "Pilih") { alert('Mohon isi tanggal lahir anda.'); frm.Birthdate.focus(); return false; }

if (frm.Birthdate2.value == "Pilih") { alert('Mohon isi bulan lahir anda.'); frm.Birthdate2.focus(); return false; }

if (frm.Birthdate3.value == "") { alert('Mohon isi tahun lahir anda.'); frm.Birthdate3.focus(); return false; }

if (frm.Nationality.value == "") { alert('Mohon isi kewarganegaraan anda.'); frm.Nationality.focus(); return false; }

if (frm.Job.value == "") { alert('Mohon isi pekerjaan anda.'); frm.Job.focus(); return false; }

if (frm.JobAddress.value == "") { alert('Mohon isi alamat perusahaan tempat anda bekerja.'); frm.JobAddress.focus(); return false; }

if (frm.JobPhone.value == "") { alert('Mohon isi nomor telepon perusahaan tempat anda bekerja.'); frm.JobPhone.focus(); return false; }

if (frm.Salary.value == "") { alert('Mohon isi penghasilan anda.'); frm.Salary.focus(); return false; }

if (frm.Address.value == "") { alert('Mohon isi alamat domisili anda.'); frm.Address.focus(); return false; }

if (frm.Phone.value == "") { alert('Mohon isi nomor telepon rumah anda.'); frm.Phone.focus(); return false; }

if (frm.Mobile.value == "") { alert('Mohon isi nomor ponsel anda.'); frm.Mobile.focus(); return false; }

if (frm.FromEmailAddress.value == "") { alert('Mohon isi alamat email anda.'); frm.FromEmailAddress.focus(); return false; }

if (frm.FromEmailAddress.value.indexOf("@") < 1 || frm.FromEmailAddress.value.indexOf(".") < 1) { alert('Tolong masukkan alamat email anda dengan benar.'); frm.FromEmailAddress.focus(); return false; }

if (frm.Message.value == "") {alert('Mohon isi pesan yang ingin anda sampaikan.');frm.Message.focus();return false;}

return true; }

</script>

<div style="text-align: center;">

<span style="font-size: x-large;">Form Pendaftaran</span></div>

<br />

<table width="100%;" align="center">

<tbody>

<tr><td><u><span style="font-size: large;">Data Pribadi</span></u></td></tr>

<tr><td><label for="Name">Nama Depan</label>       <br />

<input maxlength="50" name="Name" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="LastName">Nama Belakang</label>   <br />

<input maxlength="50" name="LastName" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="Gender">Jenis Kelamin</label>  <br />

<input checked="checked" name="Gender" type="radio" value="Pria" /> Pria 

<input name="Gender" type="radio" value="Wanita" /> Wanita</td></tr>

<tr><td><label for="Birthplace">Tempat Lahir</label>     <br />

<input maxlength="50" name="Birthplace" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="Birthdate">Tanggal Lahir</label><br />

<select name="Birthdate"><option value="Pilih">Pilih</option>

<option value="1">1</option>

<option value="2">2</option>

<option value="3">3</option>

<option value="4">4</option>

<option value="5">5</option>

<option value="6">6</option>

<option value="7">7</option>

<option value="8">8</option>

<option value="9">9</option>

<option value="10">10</option>

<option value="11">11</option>

<option value="12">12</option>

<option value="13">13</option>

<option value="14">14</option>

<option value="15">15</option>

<option value="16">16</option>

<option value="17">17</option>

<option value="18">18</option>

<option value="19">19</option>

<option value="20">20</option>

<option value="21">21</option>

<option value="22">22</option>

<option value="23">23</option>

<option value="24">24</option>

<option value="25">25</option>

<option value="26">26</option>

<option value="27">27</option>

<option value="28">28</option>

<option value="29">29</option>

<option value="30">30</option>

<option value="31">31</option>

</select><label for="Birthdate2"></label>- <select name="Birthdate2"><option value="Pilih">Pilih</option>

<option value="Januari">Januari</option>

<option value="Februari">Februari</option>

<option value="Maret">Maret</option>

<option value="April">April</option>

<option value="Mei">Mei</option>

<option value="Juni">Juni</option>

<option value="Juli">Juli</option>

<option value="Agustus">Agustus</option>

<option value="September">September</option>

<option value="Oktober">Oktober</option>

<option value="November">November</option>

<option value="Desember">Desember</option>

</select><label for="Birthdate3"></label> -

<input max="2017" maxlength="50" min="1950" name="Birthdate3" style="width: 90px;" type="number" /></td></tr>

<tr><td><label for="Nationality">Kewarganegaraan</label>   <br />

<input maxlength="50" name="Nationality" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="Education">Pendidikan Terakhir</label>   <br />

<input checked="checked" name="Salary" type="radio" value="SD/SEDERAJAT" /> SD/SEDERAJAT<br />

<input name="Salary" type="radio" value="SMP/SEDERAJAT" /> SMP/SEDERAJAT<br />

<input name="Salary" type="radio" value="SMA/SEDERAJAT" /> SMA/SEDERAJAT<br />

<input name="Salary" type="radio" value="DIPLOMA" /> DIPLOMA<br />

<input name="Salary" type="radio" value="S1" /> S1<br />

<input name="Salary" type="radio" value="S2" /> S2<br />

<input name="Salary" type="radio" value="S3" /> S3 </td></tr>

<tr><td><u><span style="font-size: large;">Data Pekerjaan</span></u></td></tr>

<tr><td><label for="Job">Pekerjaan</label>   <br />

<input maxlength="50" name="Job" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="JobAddress">Alamat Perusahaan</label>   <br />

<input maxlength="50" name="JobAddress" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="JobPhone">Nomor Telepon Perusahaan</label>   <br />

<input maxlength="50" name="JobPhone" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="Salary">Penghasilan Bulanan</label>  <br />

<input checked="checked" name="Salary" type="radio" value="< Rp 1.000.000" /> < Rp 1.000.000<br />

<input name="Salary" type="radio" value="Rp 1.000.000 - Rp 2.499.999" /> Rp 1.000.000 - Rp 2.499.999<br />

<input name="Salary" type="radio" value="Rp 2.500.000 - Rp 4.999.999" /> Rp 2.500.000 - Rp 4.999.999<br />

<input name="Salary" type="radio" value="Rp 5.000.000 - Rp 9.999.999" /> Rp 5.000.000 - Rp 10.000.000<br />

<input name="Salary" type="radio" value="> Rp 10.000.000" /> > Rp 10.000.000 </td></tr>

<tr><td><u><span style="font-size: large;">Kontak</span></u></td></tr>

<tr><td><label for="Phone">Nomor Telepon Rumah</label>   <br />

<input maxlength="50" name="Phone" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="Mobile">Nomor Ponsel</label>   <br />

<input maxlength="50" name="Mobile" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="Address">Alamat Domisili</label>   <br />

<input maxlength="50" name="Address" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="FromEmailAddress">Alamat Email</label>     <br />

<input maxlength="50" name="FromEmailAddress" style="width: 290px;" type="text" /></td></tr>

<tr><td><label for="Message">Pesan</label><br />

<textarea cols="38" name="Message" rows="5" style="height: 100 px;" wrap="hard">(/textarea)</td></tr>

<tr><td><script src="https://www.100forms.com/js/FORMKEY:MY3RN65JU78A/SEND:XXXX@XXXX.com" type="text/javascript"></script>

<input name="skip_Reset" type="reset" value="RESET" /><input id="skip_Submit" name="skip_Submit" type="submit" value="DAFTAR" />

</td></tr>

</tbody></table>

</form>