<html>
<head><title>FORMULIR PENDAFTARAN</title><link rel="stylesheet" type="text/css" href="body.css"/></head>
<body>
<div id="tabel">
<form action="output.php" method="post">
<table width="700" border="0" align="center" cellpadding="2" cellspacing="0" style="padding: 3px">
<tr>
<tr><td><i><marquee>Perpustakaan Wilayah SOEMAN HS</marquee></i></td></tr>
<td height="40" align="center">
<b>FORMULIR DATA PEMOHON JADI ANGGOTA</b></td>
</tr>
<tr>
<td ><center><img width=""160" height="160"src="riau.PNG"></center></td>
</tr>
<tr>
<td ><table width="650" border="0" align="center" cellpadding="5" cellspacing="0">
<tr>
<td width="113">Nama Lengkap</td><td width="11">:</td>
<td width="237"><input name="nama" type="text" size="47" maxlength="47"></td>
</tr>
<tr>
<td>Tempat/Tanggal Lahir</td><td>:</td>
<td><input name="temp" type="text" size="15" maxlength="15">
</select><select name="tgl">
<option value=01>01</option><option value=02>02</option><option value=03>03</option>
<option value=04>04</option><option value=05>05</option><option value=06>06</option>
<option value=07>07</option><option value=08>08</option><option value=09>09</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><select name="bln">
<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=-Septermber>September</option>
<option value=-Oktober>Oktober</option><option value=-November>November</option>
<option value=-Desember>Desember</option>
</select><select name="thn">
<option value=-1980>1980</option><option value=-1981>1981</option><option value=-1982>1982</option>
<option value=-1983>1983</option><option value=-1984>1984</option><option value=-1985>1985</option>
<option value=-1986>1986</option><option value=-1987>1987</option><option value=-1988>1988</option>
<option value=-1989>1989</option><option value=-1990>1990</option><option value=-1991>1991</option>
<option value=-1992>1992</option><option value=-1993>1993</option><option value=-1994>1994</option>
<option value=-1995>1995</option><option value=-1996>1996</option><option value=-1997>1997</option>
<option value=-1998>1998</option><option value=-1999>1999</option><option value=-2000>2000</option>
</select></td>
</tr>
<tr>
<td>Agama</td>
<td>:</td>
<td><input name="agama" type="text" size="15" maxlength="15"></td>
</tr>
<tr>
<td>Alamat</td>
<td>:</td>
<td><textarea name="alamat" cols="37" rows="3"></textarea></td>
</tr>
<tr>
<td>Menggunakan Identitas</td>
<td>:</td>
<td>
<input type="radio" name="iden" value="KTP">KTP
<input type="radio" name="iden" value="KTM">KTM
<input type="radio" name="iden" value="Kartu Pelajar">Kartu Pelajar
</td>
</tr>
<tr>
<td>No. Identitas</td>
<td>:</td>
<td><input name="noid" type="text" size="47" maxlength="20"></td>
</tr>
<tr>
<td>No. HP</td>
<td>:</td>
<td><input name="nope" type="text" size="47" maxlength="15"></td>
</tr>
<tr>
<td>Pendidikan Terakhir</td>
<td>:</td>
<td>
<input type="radio" name="ptr" value="SD">SD
<input type="radio" name="ptr" value="SMP">SMP
<input type="radio" name="ptr" value="SMA">SMA
<input type="radio" name="ptr" value="S1">S1
<input type="radio" name="ptr" value="S2">S2
<input type="radio" name="ptr" value="S3">S3
</td>
</tr>
<tr>
<td>Pekerjaan</td>
<td>:</td>
<td>
<input type="radio" name="kerja" value="PNS">PNS
<input type="radio" name="kerja" value="Karyawan">Karyawan
<input type="radio" name="kerja" value="Wiraswasta">Wiraswasta
<input type="radio" name="kerja" value="Mahasiswa">Mahasiswa
<input type="radio" name="kerja" value="Pelajar">Pelajar
</td>
</tr>
<tr>
<td>Nama Intansi/Univ/Sekolah</td>
<td>:</td>
<td><textarea name="nain" cols="37" rows="3"></textarea></td>
</tr>
<tr>
<td>Alamat Intansi/Univ/Sekolah</td>
<td>:</td>
<td><textarea name="alin" cols="37" rows="3"></textarea></td>
</tr>
<tr>
<td>UserName</td>
<td>:</td>
<td><input type="text" name="user" size="20"></td>
</tr>
<tr>
<td>Password</td>
<td>:</td>
<td><input type="password" name="pass" size="20"></td>
</tr>
<tr>
<td></td>
<td></td>
<td><input type="submit" name="simpan"target="new" value="SIMPAN"><input type="reset" value="Reset"> </td>
</tr>
</td>
</tr>
</table>
</table>
</form>
</div>
</body>
</html>
2. body.css
body {
margin:0 auto;
background:url(puswil.jpg) no-repeat fixed top center;
background-size: cover;
-webkit-background-size:cover;
color:#00FF00
}
#tabel {
margin:10px auto;
padding:20px;
width:800px;
border:1px solid #888;
background:url(blank.png) repeat top left;
}
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