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<?php include "header.php"; ?>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<title>IDI</title>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="stylesheet" href="style2.css">
<link rel="icon" href="idilogo.png">
<!-- Bootstrap core CSS -->
<link href="../assets/css/bootstrap.min.css" rel="stylesheet">
<!-- Custom styles for this template -->
<link href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css" rel="stylesheet" />
<style type="text/css">
<!--
-->
@import url(http://fonts.googleapis.com/css?family=Montserrat:400,700);
html{
background:url(image/medical.jpg) no-repeat;
background-size: cover;
height:100%;
}
#feedback-page{
text-align:center;
}
#form-main{
width:100%;
float:left;
padding-top:0px;
}
#form-div {
border: #8C8C8C solid 2px;
background-color:rgba();
padding-left:35px;
padding-right:35px;
padding-top:35px;
padding-bottom:50px;
width: 650px;
float: left;
left: 50%;
position: absolute;
margin-top:30px;
margin-left: -260px;
-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: 150px;
line-height: 150%;
resize:vertical;
}
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: #00CAE1;
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;
}
body {font-family: Arial, Helvetica, sans-serif;}
* {box-sizing: border-box;}
.input-container {
display: -ms-flexbox; /* IE10 */
display: flex;
width: 100%;
margin-bottom: 15px;
}
.icon {
padding: 10px;
background: dodgerblue;
color: white;
min-width: 50px;
text-align: center;
}
.input-field {
width: 100%;
padding: 10px;
outline: none;
}
.input-field:focus {
border: 2px solid dodgerblue;
}
/* Atur style untuk submit button */
.btn {
background-color: dodgerblue;
color: white;
padding: 15px 20px;
border: none;
cursor: pointer;
width: 100%;
opacity: 0.9;
}
.btn:hover {
opacity: 1;
}
input[type="radio"] {
-ms-transform: scale(1.5); /* Untu IE */
-webkit-transform: scale(1.5); /* untuk Chrome, Mozilla,Safari, Opera */
transform: scale(1.5);
}
@media only screen and (max-width: 580px) {
#form-div{
left: 3%;
margin-right: 3%;
width: 88%;
margin-left: 0;
padding-left: 3%;
padding-right: 3%;
}
</style>
<div class="container">
<div id="form-main">
<div id="form-div">
<?php
// https://www.malasngoding.com
// menghubungkan dengan koneksi database
// mengambil data barang dengan kode paling besar
$tglBayar = date('Y-m-d');
$project ='Ikatan Dokter Indonesia Cabang Kota Bandung';
//$tanggal = '2015-06-03';
?>
<h3>Registrasi Anggota Baru</h3>
<br>
<form method="POST" action="multi6.php" enctype="multipart/form-data" >
<input name="project" class="form-control" readonly value="<?php echo $project ?>" />
</p>
<label for="ket">Tanggal Daftar</label>
<input name="tglreg" class="form-control" readonly type="text" id="datepicker" value="<?php echo $tglBayar ?>" size="11"></b>
</p>
*Registrasi Online Baik bagi Anggota/Nonanggota hanya cukup 1x.<br> <br>
Bagi Anggota/Nonanggota yang sudah Memiliki ID Login, dan akan mengajukan Rekomendasi kembali,<br>
Silahkan langsung Login dengan <b>'ID dan Password'</b> yang sudah ada, tanpa perlu Registrasi ulang kembali. <br><br>
<label for="jumlah"><b>*Lupa ID Login (Bagi yang pernah Registrasi lupa ID Login)</b></label> <br>
<span class="psw"> <a href="../forgot_id.php"><b> Lupa ID Login? Click disini...</b></a></span>
<br> <br>
<br>
<label for="jumlah">Pilih Tujuan Registras :</label>
<br>*Click Tanda bulat
</p>
<input type="radio" name="anggota" value="1" > <b> Anggota IDI Kota Cabang Bandung.</b> <br>
</P>
Sudah terdaftar sebagai Anggota IDI Cabang Kota Bandung secara manual.<br>
<b> 1. Tujuan akan Registrasi ulang keanggotaan secara Online.</b><br><br>
<div>
<input type="radio" name="anggota" value="2" checked ><b> Non anggota/Tamu/Internsip.</b><br>
</div></P>
Belum pernah terdaftar menjadi Anggota IDI Cabang Kota Bandung.<br>
<b>1. Tujuan Registrasi anggota baru (fresh)/mutasi dari kota lain ke IDI Kota Bandung.<br>
2. Tujuan pengajuan Rekom SIP di Kota Bandung sebagai Tamu.<br>
3. Tujuan pengajuan Internsip.</b> <br>
<br> <br>
<label for="sales">Nama User</label>
<div class="input-container">
<i class="fa fa-user icon"></i>
<input class="input-field" type="text" placeholder="Isi Nama" name="nama">
</div>
<label for="sales">Mobile No (ISI kode negara :628XXX)</label>
<div class="input-container">
<i class="fa fa-phone icon"></i>
<input class="input-field" type="number" placeholder="Isi Phone No" name="telp">
</div>
<label for="sales">Email</label>
<div class="input-container">
<i class="fa fa-envelope icon"></i>
<input class="input-field" type="email" placeholder="Isi Alamat Email" name="email">
</div>
<label for="sales">Password</label>
<div class="input-container">
<i class="fa fa-key icon"></i>
<input name="password" class="input-field" type="" placeholder="Isi Password" >
</div>
<br>
<div class="form-group">
<label for="sales">Input Kode Captcha</label><br>
<img src="generate.php" alt="gambar" />
</div>
<div class="form-group">
<input class="form-control" name="kode" value="" placeholder="Input kode captcha " maxlength="5"/>
</p>
<p> </p>
<div class="submit">
<input type="submit" id="button-blue" value="Submit" />
<div class="ease">
</div>
<br>
*Konfirmasi Registrasi akan dikirim via email dan no WA.<br> pastikan email dan No WA anda Valid
</div>
</form>
</div>