form pendaftaran

form_daftar.php

+<?php 
+require_once(dirname(__FILE__).'/koneksi.php');
+require_once(dirname(__FILE__).'/common/header.php');
+?>
+<form class="well form-horizontal" action="cek_daftar.php" method="post"  id="contact_form">
+<fieldset>
+<legend>Member Registration</legend>
+<div class="form-group">
+  <label class="col-md-4 control-label">Nama</label>  
+  <div class="col-md-4 inputGroupContainer">
+  <div class="input-group">
+  <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
+  <input  name="name" required placeholder="Isi Nama Anda" class="form-control"  type="text">
+    </div>
+  </div>
+</div>
+<div class="form-group">
+  <label class="col-md-4 control-label">Alamat</label>  
+    <div class="col-md-4 inputGroupContainer">
+    <div class="input-group">
+        <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
+  <input name="address" required placeholder="Isi alamat Anda" class="form-control" type="text">
+    </div>
+  </div>
+</div>
+<div class="form-group">
+  <label class="col-md-4 control-label">Hp #</label>
+    <div class="col-md-4 inputGroupContainer">
+    <div class="input-group">
+        <span class="input-group-addon"><i class="glyphicon glyphicon-earphone"></i></span>
+  <input name="phone" required placeholder="Nomor Handphone" class="form-control" type="text">
+    </div>
+  </div>
+</div>
+<div class="form-group">
+  <label class="col-md-4 control-label">Email </label>
+    <div class="col-md-4 inputGroupContainer">
+    <div class="input-group">
+        <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
+  <input name="email" required placeholder="E-mail" class="form-control" type="text">
+    </div>
+  </div>
+</div>
+<div class="form-group">
+  <label class="col-md-4 control-label">Username</label>  
+    <div class="col-md-4 inputGroupContainer">
+    <div class="input-group">
+        <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
+        <input name="username" required placeholder="Isi username anda" class="form-control"  type="text">
+    </div>
+  </div>
+</div>
+<div class="form-group">
+  <label class="col-md-4 control-label">Password</label> 
+    <div class="col-md-4 inputGroupContainer">
+    <div class="input-group">
+    <span class="input-group-addon"><i class="glyphicon glyphicon-lock"></i></span>
+    <input name="password" required placeholder="Password" class="form-control"  type="password">
+    </div>
+  </div>
+</div> 
+<div class="form-group">
+  <label class="col-md-4 control-label">Ulangi Password</label> 
+    <div class="col-md-4 inputGroupContainer">
+    <div class="input-group">
+    <span class="input-group-addon"><i class="glyphicon glyphicon-lock"></i></span>
+    <input name="repass" required placeholder="Ulangi Password anda" class="form-control"  type="password">
+    </div>
+  </div>
+</div> 
+<div class="form-group">
+  <label class="col-md-4 control-label"></label>
+  <div class="col-md-4">
+    <button type="submit" class="btn btn-warning" > Daftar <span class="glyphicon glyphicon-send"></span></button>
+  </div>
+</div>
+</fieldset>
+</form>
+<?php
+require_once(dirname(__FILE__).'/common/footer.php');
+?>