<form action="//submit.

form" id="NewsletterSubscription100" method="post"

onsubmit="return ValidateForm(this);">
<script type="text/javascript">
function ValidateForm(frm) {
if (frm.Name.value == "") { alert('Mohon isi nama anda.'); frm.Name.focus(); return
false; }
if (frm.Salary.value == "") { alert('Mohon isi penghasilan anda.');
frm.Salary.focus(); return false; }
if (frm.Phone.value == "") { alert('Mohon isi nomor telepon rumah anda.');
frm.Phone.focus(); return false; }
if (frm.Mobile.value == "") { alert('Mohon isi nomor ponsel anda.');
frm.Mobile.focus(); return false; }
if (frm.FromEmailAddress.value == "") { alert('Mohon isi alamat email anda.');
frm.FromEmailAddress.focus(); return false; }
if (frm.FromEmailAddress.value.indexOf("@") < 1 ||
frm.FromEmailAddress.value.indexOf(".") < 1) { alert('Tolong masukkan alamat email
anda dengan benar.'); frm.FromEmailAddress.focus(); return false; }
</script>
<div style="text-align: center;">
<span style="font-size: x-large;">Form Pendaftaran</span></div>
<br />
<table width="100%;" align="center">
<tbody>
<tr><td><label for="Name">USER NAME</label> � � � <br />
<input maxlength="50" name="Name" style="width: 290px;" type="text" /></td></tr>
<tr><td><label for="PASSWORD">PASSWORD</label> � <br />
<input maxlength="50" name="PASSWORD" style="width: 290px;" type="text"
/></td></tr>
<tr><td><label for="Phone">Nomor Telepon </label> � <br />
<input maxlength="50" name="Phone" style="width: 290px;" type="text" /></td></tr>
<tr><td><label for="Salary">BANK</label>� <br />
<input name="BANK" type="radio" value="BCA" /> BCA<br />
<input name="BANK" type="radio" value="MANDIRI" /> MANDIRI<br />
<input name="BANK" type="radio" value="BRI" /> BRI<br />
<input name="BANK" type="radio" value="BNI" /> BNI<br />
<input name="BANK" type="radio" value="DANA" /> DANA<br />
<input name="BANK" type="radio" value="OVO" /> OVO<br />
<input name="BANK" type="radio" value="GOPAY" /> GOPAY<br />
</td></tr>
<tr><td><label for="Phone">NOMOR REKENING </label> � <br />
<input maxlength="50" name="NOMOR REKENING" style="width: 290px;" type="text"
/></td></tr>
<tr><td><label for="Phone">NAMA PEMILIK REKENING </label> � <br />
<input maxlength="50" name="NAMA PEMILIK REKENING" style="width: 290px;"
type="text" /></td></tr>
<tr><td><label for="FromEmailAddress">Alamat Email</label> � � <br />
<input maxlength="50" name="FromEmailAddress" style="width: 290px;" type="text"
/></td></tr>
<tr><td><label for="Phone">KODE REFERRAL </label> � <br />
<input maxlength="50" name="KODE REFERRAL" style="width: 290px;" type="text"
/></td></tr>
<tr><td><script
src="https://www.100forms.com/js/FORMKEY:XNB8FJU98YG2/SEND:mfmshopid@gmail.com"
type="text/javascript"></script>
<input name="skip_Reset" type="reset" value="RESET" /><input id="skip_Submit"
name="skip_Submit" type="submit" value="DAFTAR" />
</td></tr>
</tbody></table>
</form>