/home/kkco/www/pascasarjana__2939f42/page/pendaftaran_online.php
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" /><form id="emf-form" target="_self" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/WV6tOP00Hf62rCDFanMy">
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<font face="Verdana" size="2" color="#000000"><b style="font-size:15px;">FORMULIR PENDAFTARAN ONLINE</b><br /><label style="font-size:12px;">Program Kelas Karyawan Universitas Sangga Buana<br /></label><br /></font>
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</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_0" name="element_0">
<font face="Verdana" size="2" color="#000000">
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</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana">Untuk memudahkan anda dalam proses pendaftaran, Silahkan form Pendaftaran isi Online di bawah ini dengan baik dan benar</font></small></div>
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</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_1" name="element_1">
<font face="Verdana" size="2" color="#000000">
PILIHAN PROGRAM STUDI
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</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_2" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Program Studi</b></font>
<span style="color:red;"><small>*</small></span>
<select id="element_2" name="element_2" class="form-control validate[required]"><option value=""selected="selected">Pilih Program Studi</option><option value="Akuntansi S1">Akuntansi S1</option><option value="Akuntansi D3">Akuntansi D3</option><option value="Manajemen S1">Manajemen S1</option><option value="Manajemen D3">Manajemen D3</option><option value="Teknik Sipil S1">Teknik Sipil S1</option><option value="Teknik Industri S1">Teknik Industri S1</option><option value="Teknik Mesin S1">Teknik Mesin S1</option><option value="Teknik Elektro S1">Teknik Elektro S1</option><option value="Teknik Informatika S1">Teknik Informatika S1</option><option value="Sistem Informasi S1">Sistem Informasi S1</option><option value="Administrasi Bisnis S1">Administrasi Bisnis S1</option><option value="Ilmu Komunikasi S1">Ilmu Komunikasi S1</option><option value="Magister Manajemen S2">Magister Manajemen S2</option><option value="Magister Teknik Sipil S2">Magister Teknik Sipil S2</option></select><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_3" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Waktu Kuliah</b></font>
<span style="color:red;"><small>*</small></span>
<select id="element_3" name="element_3" class="form-control validate[required]"><option value=""selected="selected">Pilih Waktu Kuliah</option><option value="Kelas Malam">Kelas Malam</option><option value="Kelas Jumat (Malam) dan Sabtu">Kelas Jumat (Malam) dan Sabtu</option></select><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_4" name="element_4">
<font face="Verdana" size="2" color="#000000">
NAMA DAN ALAMAT
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</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana">Silahkan isi Nama Lengkap dan Alamat Anda</font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_5" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Nama Lengkap</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_5" name="element_5" value="" size="45"
class="form-control validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_6" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Alamat</b></font>
<span style="color:red;"><small></small></span>
<input id="element_6" name="element_6" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_7" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>No Rumah</b></font>
<span style="color:red;"><small></small></span>
<input id="element_7" name="element_7" value="" size="3"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_8" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>RT/RW</b></font>
<span style="color:red;"><small></small></span>
<input id="element_8" name="element_8" value="" size="6"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_9" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Kota/Kabupaten</b></font>
<span style="color:red;"><small></small></span>
<input id="element_9" name="element_9" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_10" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Propinsi</b></font>
<span style="color:red;"><small></small></span>
<input id="element_10" name="element_10" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_11" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Kode Pos</b></font>
<span style="color:red;"><small></small></span>
<input id="element_11" name="element_11"
class="form-control validate[optional,custom[onlyNumber]]"
value="" size="8" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_12" name="element_12">
<font face="Verdana" size="2" color="#000000">
KONTAK
</font>
</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana">Silahkan isi Email, No HP dan Telepon Rumah</font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_13" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Email</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_13" name="element_13"
class="form-control validate[required,custom[email]]"
value="" size="30" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_14" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>No. HP</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_14" name="element_14"
class="form-control validate[required,custom[onlyNumber]]"
value="" size="30" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_15" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Telepon Rumah</b></font>
<span style="color:red;"><small></small></span>
<input id="element_15" name="element_15"
class="form-control validate[optional,custom[telephone]]"
value="" size="30" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_16" name="element_16">
<font face="Verdana" size="2" color="#000000">
TEMPAT DAN TANGGAL LAHIR
</font>
</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_17" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Tempat Lahir</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_17" name="element_17" value="" size="30"
class="form-control validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_18" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Tanggal Lahir</b></font>
<span style="color:red;"><small>*</small></span>
<table cellpadding='0' cellspacing='0' border='0'><tr><td style='padding-left:3px;padding-right:3px;'><select id="element_18_year-dd" name="element_18_day"><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><br /><font face="Verdana" size="2" color="#000000">DD</font></td><td style="padding-top:5px" valign="top"><font face="Verdana" size="2" color="#000000">/</font></td><td style='padding-left:0;padding-right:3px;'><select id="element_18_year-mm" name="element_18_month"><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></select><br /><font face="Verdana" size="2" color="#000000">MM</font></td><td style="padding-top:5px" valign="top"><font face="Verdana" size="2" color="#000000">/</font></td><td style='padding-left:3px;padding-right:3px;'><select id="element_18_year" name="element_18_year"><option value="1920" >1920</option><option value="1921" >1921</option><option value="1922" >1922</option><option value="1923" >1923</option><option value="1924" >1924</option><option value="1925" >1925</option><option value="1926" >1926</option><option value="1927" >1927</option><option value="1928" >1928</option><option value="1929" >1929</option><option value="1930" >1930</option><option value="1931" >1931</option><option value="1932" >1932</option><option value="1933" >1933</option><option value="1934" >1934</option><option value="1935" >1935</option><option value="1936" >1936</option><option value="1937" >1937</option><option value="1938" >1938</option><option value="1939" >1939</option><option value="1940" >1940</option><option value="1941" >1941</option><option value="1942" >1942</option><option value="1943" >1943</option><option value="1944" >1944</option><option value="1945" >1945</option><option value="1946" >1946</option><option value="1947" >1947</option><option value="1948" >1948</option><option value="1949" >1949</option><option value="1950" >1950</option><option value="1951" >1951</option><option value="1952" >1952</option><option value="1953" >1953</option><option value="1954" >1954</option><option value="1955" >1955</option><option value="1956" >1956</option><option value="1957" >1957</option><option value="1958" >1958</option><option value="1959" >1959</option><option value="1960" >1960</option><option value="1961" >1961</option><option value="1962" >1962</option><option value="1963" >1963</option><option value="1964" >1964</option><option value="1965" >1965</option><option value="1966" >1966</option><option value="1967" >1967</option><option value="1968" >1968</option><option value="1969" >1969</option><option value="1970" >1970</option><option value="1971" >1971</option><option value="1972" >1972</option><option value="1973" >1973</option><option value="1974" >1974</option><option value="1975" >1975</option><option value="1976" >1976</option><option value="1977" >1977</option><option value="1978" >1978</option><option value="1979" >1979</option><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><option value="2001" >2001</option><option value="2002" >2002</option><option value="2003" >2003</option><option value="2004" >2004</option><option value="2005" >2005</option><option value="2006" >2006</option><option value="2007" >2007</option><option value="2008" >2008</option><option value="2009" >2009</option><option value="2010" >2010</option><option value="2011" >2011</option><option value="2012" >2012</option><option value="2013" >2013</option><option value="2014" >2014</option><option value="2015" >2015</option><option value="2016" >2016</option><option value="2017" >2017</option><option value="2018" >2018</option><option value="2019" >2019</option><option value="2020" >2020</option><option value="2021" >2021</option><option value="2022" >2022</option><option value="2023" >2023</option><option value="2024" >2024</option><option value="2025" >2025</option><option value="2026" >2026</option><option value="2027" >2027</option><option value="2028" >2028</option><option value="2029" >2029</option><option value="2030" >2030</option></select><br /><font face="Verdana" size="2" color="#000000">YYYY</font></td></tr></table><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_19" name="element_19">
<font face="Verdana" size="2" color="#000000">
DATA PRIBADI
</font>
</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana">Isilah data pribadi anda</font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_20" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Agama</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_20" name="element_20" value="" size="30"
class="form-control validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_21" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Jenis Kelamin</b></font>
<span style="color:red;"><small>*</small></span>
<select id="element_21" name="element_21" class="form-control validate[required]"><option value=""selected="selected">Silahkan Pilih</option><option value="Pria">Pria</option><option value="Wanita">Wanita</option></select><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_22" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Golongan Darah</b></font>
<span style="color:red;"><small></small></span>
<input id="element_22" name="element_22" value="" size="2"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_23" name="element_23">
<font face="Verdana" size="2" color="#000000">
DATA PEKERJAAN
</font>
</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana">Silahkan isi Data Pekerjaan jika anda sudah bekerja</font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_24" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Nama Perusahaan</b></font>
<span style="color:red;"><small></small></span>
<input id="element_24" name="element_24" value="" size="45"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_25" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Alamat Perusahaan</b></font>
<span style="color:red;"><small></small></span>
><input id="element_25" name="element_25" value="" size="45"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_26" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Bagian</b></font>
<span style="color:red;"><small></small></span>
<input id="element_26" name="element_26" value="" size="45"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_27" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Jabatan</b></font>
<span style="color:red;"><small></small></span>
<input id="element_27" name="element_27" value="" size="45"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_28" name="element_28">
<font face="Verdana" size="2" color="#000000">
DATA ORANG TUA
</font>
</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana">Silahkan isi data Orang Tua atau Wali anda</font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_29" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Nama Orang Tua</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_29" name="element_29" value="" size="45"
class="form-control validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_30" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Alamat</b></font>
<span style="color:red;"><small></small></span>
<input id="element_30" name="element_30" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_31" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>No Rumah</b></font>
<span style="color:red;"><small></small></span>
<input id="element_31" name="element_31" value="" size="3"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_32" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>RT/RW</b></font>
<span style="color:red;"><small></small></span>
<input id="element_32" name="element_32" value="" size="6"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_33" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Kota/Kabupaten</b></font>
<span style="color:red;"><small></small></span>
<input id="element_33" name="element_33" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_34" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Propinsi</b></font>
<span style="color:red;"><small></small></span>
<input id="element_34" name="element_34" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_35" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Kode Pos</b></font>
<span style="color:red;"><small></small></span>
<input id="element_35" name="element_35"
class="form-control validate[optional,custom[onlyNumber]]"
value="" size="8" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_36" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Pekerjaan</b></font>
<span style="color:red;"><small></small></span>
<select id="element_36" name="element_36" class="form-control validate[optional]"><option value="Silahkan Pilih"selected="selected">Silahkan Pilih</option><option value="Swasta">Swasta</option><option value="PNS/TNI/POLRI">PNS/TNI/POLRI</option><option value="Pensiunan">Pensiunan</option><option value="Karyawan BUMN/BUMD">Karyawan BUMN/BUMD</option><option value="Wirawswasta">Wirawswasta</option></select><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_37" name="element_37">
<font face="Verdana" size="2" color="#000000">
DATA SEKOLAH ASAL ATAU PERGURUAN TINGGI (PT) ASAL
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</tr><tr valign="top" ><td id="td_element_label_38" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Nama Sekolah/PT</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_38" name="element_38" value="" size="30"
class="form-control validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_39" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Jurusan</b></font>
<span style="color:red;"><small>*</small></span>
<input id="element_39" name="element_39" value="" size="20"
class="form-control validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_40" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Tahun Lulus</b></font>
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<input id="element_40" name="element_40" value="" size="8"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_41" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Alamat</b></font>
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<input id="element_41" name="element_41" value="" size="40"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_42" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Kota/Kabupaten</b></font>
<span style="color:red;"><small></small></span>
<input id="element_42" name="element_42" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_43" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Propinsi</b></font>
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<input id="element_43" name="element_43" value="" size="30"
class="form-control validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td colspan="2" style=""><h3 style="font-size:14px;padding:10px 0 6px 0;border-top:1px dotted #CCCCCC;margin:14px 0;position:static;" id="element_44" name="element_44">
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PERIKSA KEMBALI DATA ANDA
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</h3><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana">Silahkan periksa kembali data yang telah anda isi di atas, jika sudah benar silahkan klik tombol "KIRIM" di bawah ini</font></small></div>
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</tr><tr><td colspan="2" align="center">
<input name="element_counts" value="45" type="hidden" />
<input name="embed" value="forms" type="hidden" /><input class="btn btn-success btn-block" value="KIRIM" type="submit" />
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