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<?php include "header2.php"; ?>
<?php
// memulai session
// jika session belum dibuat, maka inisialisasi awal diberi nilai TRUE
if (!isset($_SESSION['submit'])) {
$_SESSION['submit'] = true;
}
//
?>
<head>
<style type="text/css">
<!--
-->
@import url(http://fonts.googleapis.com/css?family=Montserrat:400,700);
html{
background-size: cover;
height:100%;
font-size: 12px;
}
#feedback-page{
text-align:center;
}
#form-main{
width:100%;
float:left;
padding-top:0px;
}
#form-div {
background-image: linear-gradient(to right, #4682B4, #00FFFF, #00FA9A);
background:url() no-repeat;
padding-left:5px;
padding-right:5px;
padding-top:5px;
padding-bottom:5px;
width: 900px;
float: left;
margin-top:5px;
margin-left: 100px;
-moz-border-radius: 7px;
-webkit-border-radius: 7px;
}
.feedback-input {
color:#3c3c3c;
font-family: Helvetica, Arial, sans-serif;
font-weight:500;
font-size: 18px;
border-radius: 0;
line-height: 22px;
background-color: #fbfbfb;
padding: 13px 13px 13px 54px;
margin-bottom: 10px;
width:100%;
-webkit-box-sizing: border-box;
-moz-box-sizing: border-box;
-ms-box-sizing: border-box;
box-sizing: border-box;
border: 3px solid rgba(0,0,0,0);
}
.feedback-input:focus{
background: #fff;
box-shadow: 0;
border: 3px solid #3498db;
color: #3498db;
outline: none;
padding: 13px 13px 13px 54px;
}
.focused{
color:#30aed6;
border:#30aed6 solid 3px;
}
/* Icons ---------------------------------- */
#name{
background-image: url(http://rexkirby.com/kirbyandson/images/name.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#name:focus{
background-image: url(http://rexkirby.com/kirbyandson/images/name.svg);
background-size: 30px 30px;
background-position: 8px 5px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#email{
background-image: url(http://rexkirby.com/kirbyandson/images/email.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#email:focus{
background-image: url(http://rexkirby.com/kirbyandson/images/email.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
#comment{
background-image: url(http://rexkirby.com/kirbyandson/images/comment.svg);
background-size: 30px 30px;
background-position: 11px 8px;
background-repeat: no-repeat;
}
.textarea {
width: 100%;
height: 80px;
line-height: 150%;
resize:vertical;
padding: 10px;
}
.input:hover, textarea:hover,
input:focus, textarea:focus {
background-color:white;
}
#button-blue{
font-family: 'Montserrat', Arial, Helvetica, sans-serif;
float:left;
width: 100%;
border: #fbfbfb solid 4px;
cursor:pointer;
background-color: #3498db;
color:white;
font-size:24px;
padding-top:22px;
padding-bottom:22px;
-webkit-transition: all 0.3s;
-moz-transition: all 0.3s;
transition: all 0.3s;
margin-top:-4px;
font-weight:700;
}
#button-blue:hover{
background-color: rgba(0,0,0,0);
color: #0493bd;
}
.submit:hover {
color: #3498db;
}
.ease {
width: 0px;
height: 74px;
background-color: #fbfbfb;
-webkit-transition: .3s ease;
-moz-transition: .3s ease;
-o-transition: .3s ease;
-ms-transition: .3s ease;
transition: .3s ease;
}
.submit:hover .ease{
width:100%;
background-color:white;
}
@media only screen and (max-width: 580px) {
#form-div{
left: 3%;
margin-right: 3%;
width: 88%;
margin-left: 3%;
padding-left: 3%;
padding-right: 3%;
}
</style>
<link rel="stylesheet" href="//code.jquery.com/ui/1.12.1/themes/base/jquery-ui.css">
<script src="https://code.jquery.com/jquery-1.12.4.js"></script>
<script src="https://code.jquery.com/ui/1.12.1/jquery-ui.js"></script>
<script>
<!--
$( function() {
$( "#datepicker1" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker2" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker3" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker4" ).datepicker({ dateFormat: 'dd-mm-yy' });
$( "#datepicker5" ).datepicker({ dateFormat: 'dd-mm-yy' });
} );
function MM_findObj(n, d) { //v4.01
var p,i,x; if(!d) d=document; if((p=n.indexOf("?"))>0&&parent.frames.length) {
d=parent.frames[n.substring(p+1)].document; n=n.substring(0,p);}
if(!(x=d[n])&&d.all) x=d.all[n]; for (i=0;!x&&i<d.forms.length;i++) x=d.forms[i][n];
for(i=0;!x&&d.layers&&i<d.layers.length;i++) x=MM_findObj(n,d.layers[i].document);
if(!x && d.getElementById) x=d.getElementById(n); return x;
}
//-->
</script>
<link rel="stylesheet" href="//code.jquery.com/ui/1.12.1/themes/base/jquery-ui.css">
<script type="text/javascript">
function show(str){
document.getElementById('sh2').style.display = 'none';
document.getElementById('sh1').style.display = 'block';
}
function show2(sign){
document.getElementById('sh2').style.display = 'block';
document.getElementById('sh1').style.display = 'none';
}
</script>
</head>
<body>
<div id="wrapper">
<?php // include "sidebar.php"; ?>
<!-- Content Wrapper -->
<div id="content-wrapper" class="d-flex flex-column">
<!-- Main Content -->
<div id="content">
<?php //include "topbar.php";?>
<!-- Begin Page Content -->
<div class="container-fluid">
<!-- DataTales Example -->
<div class="card shadow mb-4">
<div class="card-header py-3">
<h6 class="m-0 font-weight-bold text-primary">List Post</h6>
</div>
<div class="card-body">
<div class="table-responsive">
<center> <img src="image/logoutama.png" width= "50" height="50">
<hr>
<p>FORM PENDAFTARAN ANGGOTA BARU<br>
IDI Kota Bandung</p><br>
Bersama ini saya mengajukan permohonan sebagai anggota IDI <br> dan saya bersedia mentaati AD/ART IDI dan ketentuan-ketentuan organisasi IDI.<br></center>
<br>
<div id="form-div">
<h4 align="center"><strong>Form Anggota IDI Cab Bandung</strong></h4>
<?php $npm=$_GET['npm']; ?>
<?php
//menampilkan data Pra registrasi
$sql=mysqli_query($konek,"SELECT * FROM chek_peserta where npm='$npm' order by id desc limit 1 ");
$data=mysqli_fetch_array($sql);
$perihal = $data['perihal'];
$anggota = $data['anggota'];
$ahli = $data['ahli'];
$jenisp = $data['jenisp'];
// $status = $data['status'];
?>
<title>Persiapan Dokumen Rekomendasi </title>
<div class="card-body">
<div class="row">
<div class="col-md-6">
<div class="form-group ">
<br>
<strong>Status Keanggotaan IDI Bandung:</strong><br>
<input type="radio" name="anggota" value="anggota_IDI"<?php if($anggota=='anggota_baru') echo 'checked'?> disabled> Registrasi Anggota Baru IDI Bandung
<br>
<br>
<strong>Keahlian : </strong><br>
<input type="radio" name="ahli" value="dokter_umum"<?php if($ahli=='dokter_umum') echo 'checked'?> disabled> Dokter Umum |
<input type="radio" name="ahli" value="spesialis"<?php if($ahli=='spesialis') echo 'checked' ?> disabled> Dokter Spesialis<br>
<br>
<strong>Tujuan :</strong><br>
<input type="radio" name="perihal" value="anggota_baru"<?php if($perihal=='anggota_baru') echo 'checked'?> disabled> Registrasi Anggota Baru <br>
<br>
<strong>Jenis Pengajuan Anggota Baru :</strong><br>
<input type="radio" name="jenisp" value="1"<?php if($jenisp=='1') echo 'checked'?> disabled> Mutasi sudah ada Nomor STR <br>
<input type="radio" name="jenisp" value="2"<?php if($jenisp=='2') echo 'checked'?> disabled> Non Mutasi / Fresh Graduate Sudah ada Nomor STR <br>
</div>
</div>
</div>
<?php
$no = 1;
$data = mysqli_query($konek, "SELECT * FROM h_anggota_reg WHERE npm='$_GET[npm]' " );
$hari = date('Y-m-d');
$hariini = date('Y-m-d');
$today = date('d-m-Y');
$d=mysqli_fetch_array($data);
// echo date('Y-m-d', strtotime($hari)); // Hasil 15 February 1994
?>
<?php
if($jenisp<>'3'){
?>
<form method="post" action="ang_baru.php" enctype="multipart/form-data">
<div class="card-body">
<div class="row">
<div class="col-md-4">
<label for="tbayar"><b>ID </b></label><br>
<input class="form-control" name="npm" readonly value="<?php echo $_GET['npm'] ?>" />
<input class="form-control" type="hidden" name="jenisp" readonly value="<?php echo $jenisp ?>" />
</p>
<label for="ket"><b>Tanggal Masuk Berkas </b></label> <br>
<input class="form-control" name="tglreg" readonly value="<?php echo $today ?>" size="11">
</p>
<label for="tbayar"><b>NO KTP </b></label>
<br>
<input class="form-control" name="ktp" type="teks" placeholder="Isi Nomor KTP" value="" required />
</p>
<label for="Gelar"><b> Gelar Depan</b> </label>
<br>
<textarea name="gdepan" class="form-control" placeholder="Gelar Depan exp: Prof.DR.dr." required></textarea>
</p>
<label for="Gelar"><b> Nama Lengkap (Tanpa Gelar)</b> </label>
<br>
<textarea name="nmlead" class="form-control" placeholder="Isi Nama lengkap (Gelar)" required><?php echo $d['nmlead'] ?></textarea>
</p>
</p>
<label for="tbayar"><b> Gelar Belakang</b> </label>
<br>
<textarea name="gbelakang" class="form-control" placeholder="Gelar Belakang exp: SpTHT-KL,M.Kes,FICS" ></textarea>
</p>
<label for="jumlah"><b>Alamat Lengkap </b></label>
<br>
<textarea name="alamat" class="form-control" placeholder="Isi Alamat" required></textarea>
</p>
<label for="jumlah"><b>Email</b></label>
<br>
<input name="email" class="form-control" type="email" placeholder="Isi Email" value="<?php echo $d['email'] ?>" required/>
</p>
<label for="jumlah"><b>Mobile No/WA</b> </label>
<br>
<input class="form-control" name="telp" type="number" placeholder="Isi No telp" maxlength="16" value="<?php echo $d['telp'] ?>" required />
</p>
</div>
<div class="col-md-4">
<!--Tanggal Lahir -->
<label for="jumlah"><b>Tempat lahir</b> </label>
<br>
<input class="form-control" type="text" placeholder="Isi Kota Lahir" name="tlahir" required >
</p>
<label for="bukti" >Tanggal Lahir ("contoh lengkap exp:29-01-1990") </b> </label>
<br>
<input class="form-control" name="tgllahir" placeholder="Format Tanggal-Bulan-Tahun, Exp:29-01-2000" id="datepicker1" value="" size="11">
</p>
<label for="jumlah"><b>Warga negara</b> </label>
<br>
<input class="form-control" name="warganegara" type="text" placeholder="Isi Warganegara" value="Indonesia" size="30" required >
</p>
<label for="jumlah"><b>Agama</b></label>
<br>
<input class="form-control" name="agama" type="text" placeholder="Isi Agama" value="" size="30" required >
</p>
<label for="jumlah"><b>Jenis Kelamin</b></label>
<br>
<input type="radio" name="gender" value="lelaki" checked> Laki-laki<br>
<input type="radio" name="gender" value="perempuan"> Perempuan <br>
</p>
<label for="jumlah" ><b>Keahlian /Dokter Umum/Spesialis</b> </label>
<br>
<textarea name="ahli" class="form-control" placeholder="Isi Keahlian Praktek sebagai" required></textarea>
</p>
<label for="bukti" ><b>Tanggal Lulus</b> </label>
<br>
<input class="form-control" name="tgllulus" id="datepicker2" placeholder="Isi Tgl Lulus, Format Tanggal Bulan Tahun" value="" size="11">
</p>
<label for="jumlah" ><b>Lulusan</b> </label>
<br>
<textarea name="lulusan" class="form-control" placeholder="Isi Lulusan" required></textarea>
</p>
</div>
<div class="col-md-4">
<div><b>Mutasi / Calon Anggota sudah ada Nomor STR :</b>
</div>
<br>
<label for="jumlah" ><b>NPA (Tanpa Kode area exp: 12345),Kosongkan jika belum punya NPA </b></label>
<br>
<input name="npa" class="form-control" placeholder="Isi NPA tanpa kode area, Exp:12345 " value="" />
</p>
<!-- <label for="tbayar" class="merah">NPA IDI Cabang Bandung</label>
<br>
<input name="npaidi" class="form-control" placeholder="Isi NPA IDI Cabang Bdg" value="" required />
</p>-->
<label for="nostr" ><b>Nomor STR</b> </label>
<br>
<input class="form-control" name="nostr" type="text" placeholder="Isi Nomor STR" maxlength="30" value="" d/>
</p>
<label for="awalmbstr" ><b>Tanggal Masa Berlaku Awal Nomor STR</b> </label>
<br>
<input class="form-control" name="awalstr" id="datepicker3" placeholder="Format Tanggal Bulan Tahun" value="" required>
</p>
<label for="mbstr" ><b>Tanggal Masa Berlaku Akhir Nomor STR</b> </label>
<br>
<input class="form-control" name="mbstr" id="datepicker4" placeholder="Format Tanggal Bulan Tahun" value="" size="11" required>
</p>
<br>
</p>
<br> <br> <br>
<label for="file"><b>UPLOAD PASS FOTO<br> Ukuran pas Foto 3x4 latar belakang merah.<br>
Format foto: jpg,jpeg atau png. </b> <br>
</label>
<p>
<input class="form-control" name="file" type="file" />
</p>
<p> </p>
<div class="submit">
<input type="submit" id="button-blue" value="Lanjut" />
<div class="ease"></div>
</div>
</form>
<?php }else{
?>
<?php
$no = 1;
$data = mysqli_query($konek, "SELECT * FROM h_anggota_reg WHERE npm='$_GET[npm]' " );
$hari = date('Y-m-d');
$hariini = date('Y-m-d');
$d=mysqli_fetch_array($data);
// echo date('Y-m-d', strtotime($hari)); // Hasil 15 February 1994
?>
<form method="post" action="ang_baru.php" enctype="multipart/form-data">
<div class="card-body">
<div class="row">
<div class="col-md-4">
<label for="tbayar"><b>ID </b></label><br>
<input class="form-control" name="npm" readonly value="<?php echo $_GET['npm'] ?>" />
</p>
<label for="ket"><b>Tanggal Masuk Berkas </b></label> <br>
<input class="form-control" name="tglreg" readonly type="date" value="<?php echo $hariini ?>" size="11">
</p>
<label for="tbayar"><b>NO KTP </b></label>
<br>
<input class="form-control" name="ktp" type="teks" placeholder="Isi Nomor KTP" value="" required />
</p>
<label for="Gelar"><b> Gelar Depan</b> </label>
<br>
<textarea name="nmlead" class="form-control" placeholder="Gelar Depan exp: Prof.DR.dr." required></textarea>
</p>
<label for="Gelar"><b> Nama Lengkap (Tanpa Gelar)</b> </label>
<br>
<textarea name="gbelakang" class="form-control" placeholder="Isi Nama lengkap (Gelar)" required><?php echo $d['nmlead'] ?></textarea>
</p>
</p>
<label for="tbayar"><b> Gelar Belakang</b> </label>
<br>
<textarea name="nmlead" class="form-control" placeholder="Gelar Belakang exp: SpTHT-KL,M.Kes,FICS" required></textarea>
</p>
<label for="jumlah"><b>Alamat Lengkap </b></label>
<br>
<textarea name="alamat" class="form-control" placeholder="Isi Alamat" required></textarea>
</p>
<label for="jumlah"><b>Email</b></label>
<br>
<input name="email" class="form-control" type="email" placeholder="Isi Email" value="<?php echo $d['email'] ?>" required/>
</p>
<label for="jumlah"><b>Mobile No/WA</b> </label>
<br>
<input class="form-control" name="telp" type="number" placeholder="Isi No telp" maxlength="16" value="<?php echo $d['telp'] ?>" required />
</p>
</div>
<div class="col-md-4">
<!--Tanggal Lahir -->
<label for="jumlah"><b>Tempat lahir</b> </label>
<br>
<input class="form-control" type="text" placeholder="Isi Kota Lahir" name="tlahir" required >
</p>
<label for="bukti" >Tanggal Lahir ("Ketik dalam kotak") </b> </label>
<br>
<input class="form-control" name="tgllahir" placeholder="Format Tanggal-Bulan-Tahun, Exp:29-01-2000" id="datepicker" value="" size="11">
</p>
<label for="jumlah"><b>Warga negara</b> </label>
<br>
<input class="form-control" name="warganegara" type="text" placeholder="Isi Warganegara" value="Indonesia" size="30" required >
</p>
<label for="jumlah"><b>Agama</b></label>
<br>
<input class="form-control" name="agama" type="text" placeholder="Isi Agama" value="" size="30" required >
</p>
<label for="jumlah"><b>Jenis Kelamin</b></label>
<br>
<input type="radio" name="gender" value="lelaki" checked> Laki-laki<br>
<input type="radio" name="gender" value="perempuan"> Perempuan <br>
</p>
<label for="jumlah" ><b>Keahlian /Dokter Umum/Spesialis</b> </label>
<br>
<textarea name="ahli" class="form-control" placeholder="Isi Keahlian Praktek sebagai" required></textarea>
</p>
<label for="bukti" ><b>Tanggal Lulus</b> </label>
<br>
<input class="form-control" name="tgllulus" id="datepicker2" placeholder="Isi Tgl Lulus, Format Tanggal Bulan Tahun" value="" size="11">
</p>
<label for="jumlah" ><b>Lulusan</b> </label>
<br>
<textarea name="lulusan" class="form-control" placeholder="Isi Lulusan" required></textarea>
</p>
</div>
<div class="col-md-4">
<div>Non Mutasi/Calon Anggota belum ada Nomor STR :
</div>
<p> </p>
<div id="sh2" style="display:none;">
<br>
<!-- <label for="tbayar" class="merah">NPA IDI Cabang Bandung</label>
<br>
<input name="npaidi" class="form-control" placeholder="Isi NPA IDI Cabang Bdg" value="" required />
</p>-->
<input name="npa" class="form-control" type="hidden" placeholder="Isi NPA Pusat" value="" />
<!-- <label for="tbayar" class="merah">NPA IDI Cabang Bandung</label>
<br>
<input name="npaidi" class="form-control" placeholder="Isi NPA IDI Cabang Bdg" value="" required />
</p>-->
<input class="form-control" type="hidden" name="nostr" type="text" placeholder="Isi Nomor STR" maxlength="30" value="" d/>
<input class="form-control" type="hidden" name="awalmbstr" type="date" value="" size="11">
<input class="form-control" type="hidden" name="mbstr" id="datepicker3" placeholder="Format Tanggal Bulan Tahun" value="" size="11">
</div>
</p>
<br> <br> <br>
<label for="file"><b>UPLOAD PASS FOTO<br> Ukuran pas Foto 3x4 latar belakang merah.<br>
Format foto: jpg,jpeg atau png. </b> <br>
</label>
<p>
<input class="form-control" name="file" type="file" />
</p>
<p> </p>
<div class="submit">
<input type="submit" id="button-blue" value="Lanjut" />
<div class="ease"></div>
Note* Boleh dikosongkan
</div>
</form>
<div>
<div>
<?php
}
?>
</div>