TUP - Form Reg - HS

by DzikrRully

HTML

<p style="margin-top: 10px;margin-left: 10px;">Silahkan isi form registrasi di bawah ini.
	
	<br/>(atau silahkan hubungi marketing)

</p>
<form class="form-horizontal" method="post" action="https://report.pulsaku.info/formagen.php?id=b4b52ae9d0a33bba579a4435cb1af96f194c2670645ba66a52fec8bd0ea51a5e5480ac02323da9d10d3bca75e49ddfbea10b-62" style="margin-top: 20px;margin-left: 10px;">
	<fieldset>
		<div class="control-group">
			<label class="control-label" for="input01" style="text-align: left;padding-left: 20px;">Nama *</label>
			<div class="controls">
				<input type="text" name="namalengkap" class="input-xlarge" id="input01" maxlength="20" />
			</div>
		</div>
		<div class="control-group">
			<label class="control-label" for="input2" style="text-align: left;padding-left: 20px;">Alamat *</label>
			<div class="controls">
				<input type="text" name="alamat" class="input-xlarge" id="input2" maxlength="50" />
			</div>
		</div>
		<div class="control-group">
			<label class="control-label" for="input03" style="text-align: left;padding-left: 20px;">No HP *</label>
			<div class="controls">
				<input type="text" name="hp" class="input-xlarge" id="input03" maxlength="14" />
			</div>
		</div>
		<div class="control-group">
			<label class="control-label" for="input12" style="text-align: left;padding-left: 20px;">Verifikasi *</label>
			<div class="controls">
				<img src="https://report.pulsaku.info/images/captcha.php" class="imgcaptcha" id="imgcaptcha" />
				<img src="https://report.pulsaku.info/images/icon/refresh.png" id="reloadcaptcha" style="cursor: pointer;" onclick="reloadCaptcha();" />
				<br />
				<input type="text" name="captcha" class="input-xlarge" id="input12" style="margin-top: 10px;" />
			</div>
		</div>
		<div class="form-actions" style="background-color: transparent;border: 0;padding-left:110px;padding-top: 0px;margin-top: 10px;">
			<input type="hidden" name="id"...