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Cara Membuat Form Pendaftaran Dengan HTML

Cara Membuat Form Pendaftaran Dengan HTML

Copy aja HTML Code dibawa ini kedalam Notepad, lalu kemudian Save dengan Format HTML.
misalkan nama filenya Pendaftaran.html
pada Gambar, lihat code yang bertuliskan img src=politeknik.gif, diganti dengan nama gambar sesuka anda, dimana gambar itu tersimpan satu folder dengan anda menyimpan kode HTML ini.

<html>
<head>
<body background="work.gif">


<title>PENDAFTARAN MASUK POLITEKNIK ACEH</title>

<form name="frm_pendaftaran" onSubmit="return verifikasi(this)">
  <table bgcolor="black" width="75%" height="200" border="1" align="center" cellpadding="1">
    <tr>
      <td bgcolor="#56D9F5" height="200"> <table width="97%" height="121" border="0" align="center" cellpadding="3">
          <tr>
            <td width="21%" height="117"><div align="center"><img src="tut.GIF" width="100" height="100"></div></td>
            <td width="54%"><div align="center"><font size="5" face="Geneva, Arial, Helvetica, sans-serif"><strong>FORMULIR
                PENDAFTARAN<br>

                UJIAN MASUK POLITEKNIK ACEH <br>
                2011/2012</strong><br>
           
                </font></div></td>
           
               
            <td width="25%"><div align="center"><img src="Politeknikaceh.GIF" width="207" height="91"></div></td>
          </tr>
          </table></td>
         
         
           <table bgcolor="black" width="75%" height="50" border="1" align="center" cellpadding="1">
           <td bgcolor="black" height="20"> <table width="97%" height="10" border="0" align="center" cellpadding="3">
      
          <tr><marquee direction="Left"><font color="red">Selamat Datang Para Calon Mahasiswa Baru Politeknik Aceh, Desa Pango Raya, JL.Politeknik Aceh - Tepi Kali, Banda Aceh. Telp.(0651)31855</marquee></font></tr>
        </table></td>
       
       
    </tr>
    <tr>
      <td bgcolor="gray" height="27"><table width="789" border="0" align="center" cellpadding="1">

          <tr>
            <td width="25" height="28"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">1</font></td>
            <td width="202"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nomor
              Ujian</font></td>
            <td width="548"><input name="txt_no_ujian" type="text" id="txt_no_ujian" size="20"></td>
          </tr>
         
         
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="27"><table width="789" border="0" align="center" cellpadding="1">

          <tr>
            <td width="25" height="28"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">2</font></td>
            <td width="201"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nama
              Peserta</font></td>
            <td width="549"><input name="txt_nama_peserta" type="text" id="txt_nama_peserta" size="30"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="27"><table width="789" border="0" align="center" cellpadding="1">

          <tr>
            <td width="25" rowspan="2"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">3</font></td>
            <td width="200" rowspan="2"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Jenis
              Kelamin</font></td>
            <td width="171"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_jk" value="Laki-laki">
              Laki-laki</font></td>
            <td width="119"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">4.
              Status</font></td>
            <td width="252"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_status" value="Menikah">

              Menikah</font></td>
          </tr>
          <tr>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_jk" value="Perempuan">
              Perempuan</font></td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">&nbsp;</font></td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_status" value="Belum Menikah">

              Belum Menikah</font></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">5</font></td>
            <td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Tempat
              Lahir</font></td>

            <td width="545"><input name="txt_tmpt_lhr" type="text" id="txt_tmpt_lhr" size="30"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">6</font></td>
            <td width="195"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Tanggal
              Lahir</font></td>

            <td width="546">
            <select name="slc_tgl" id="slc_tgl">
              <option selected>-</option><option>1</option><option>2</option><option>3</option><option>4</option><option>5</option><option>6</option><option>7</option><option>8</option><option>9</option><option>10</option><option>11</option><option>12</option><option>13</option><option>14</option><option>15</option><option>16</option><option>17</option><option>18</option><option>19</option><option>20</option><option>21</option><option>22</option><option>23</option><option>24</option><option>25</option><option>26</option><option>27</option><option>28</option><option>29</option><option>30</option><option>31</option>
            </select>

              /
             
            <select name="slc_bln" id="slc_bln">
            <option selected>-</option><option>1</option><option>2</option><option>3</option><option>4</option><option>5</option><option>6</option><option>7</option><option>8</option><option>9</option><option>10</option><option>11</option><option>12</option>            </select>

              
            <select name="slc_thn" id="slc_thn">
            <option selected>-</option><option>1970</option><option>1971</option><option>1972</option><option>1973</option><option>1974</option><option>1975</option><option>1976</option><option>1977</option><option>1978</option><option>1979</option><option>1980</option><option>1981</option><option>1982</option><option>1983</option><option>1984</option><option>1985</option><option>1986</option><option>1987</option><option>1988</option><option>1989</option><option>1990</option><option>1991</option><option>1992</option><option>1993</option><option>1994</option><option>1995</option><option>1996</option><option>1997</option><option>1998</option><option>1999</option><option>2000</option><option>2001</option><option>2002</option><option>2003</option><option>2004</option><option>2005</option><option>2006</option><option>2007</option><option>2008</option><option>2009</option><option>2010</option><option>2011</option><option>2012</option><option>2013</option><option>2014</option><option>2015</option><option>2016</option><option>2017</option><option>2018</option><option>2019</option>           
            </select></td>

          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="240"><table width="789" border="0" align="center" cellpadding="1">
          <tr>
            <td width="26"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">7</font></td>
            <td width="199"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Alamat
              Surat</font></td>
            <td width="135"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Jalan</font></td>

            <td width="411"><input name="txt_jalan" type="text" id="txt_jalan" size="50"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Desa</font></td>
            <td><input name="txt_desa" type="text" id="txt_desa" size="50"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>

            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Kecamatan</font></td>
            <td><input name="txt_kecamatan" type="text" id="txt_kecamatan" size="50"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Kabupaten</font></td>

            <td><input name="txt_kabupaten" type="text" id="txt_kabupaten" size="50"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Provinsi</font></td>
            <td><input name="txt_provinsi" type="text" id="txt_provinsi" size="50"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>

            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Kode
              Pos</font></td>
            <td><input name="txt_kodepos" type="text" id="txt_kodepos" size="30"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Telp</font></td>

            <td><input name="txt_mhs_telp" type="text" id="txt_mhs_telp" size="30"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">HP</font></td>
            <td><input name="txt_hp" type="text" id="txt_hp" size="30"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>

            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Email</font></td>
            <td><input name="txt_email" type="text" id="txt_email" size="50"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">8</font></td>

            <td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Agama</font></td>
            <td width="545"><select name="slc_agama" id="slc_agama">
                <option selected>Islam</option>
                <option>Kristen Protestan</option>
                <option>Kristen Katholik</option>
                <option>Budha</option>

                <option>Hindu</option>
              </select></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="17"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">9</font></td>

            <td width="197"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Asal
              Sekolah</font></td>
            <td width="544"><input name="txt_sekolah" type="text" id="txt_sekolah" size="30"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="18"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">10</font></td>

            <td width="197"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Asal
              Jurusan</font></td>
            <td width="544"><input name="txt_jurusan" type="text" id="txt_jurusan" size="30"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="16"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">11</font></td>

            <td width="204"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">No.
              Ijazah</font></td>
            <td width="218"><input name="txt_ijazah" type="text" id="txt_ijazah" size="30"></td>
            <td width="143"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Tahun
              Lulus</font></td>
             <td width="166"><input name="txt_tahun_lulus" type="text" id="txt_tahun_lulus" size="10"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="33"><table width="790" border="0" align="center" cellpadding="3">

          <tr>
            <td width="20"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">12</font></td>
            <td width="199"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nilai
              Ijazah/Jumlah Pelajaran</font></td>
            <td width="179"><input name="txt_nilai_ijazah" type="text" id="txt_nilai_ijazah" size="10">
              /
              <input name="txt_jumpel_ijazah" type="text" id="txt_jumpel_ijazah" size="5"></td>
            <td width="189"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nilai
              UAN/Jumlah Pelajaran</font></td>
            <td width="161"><input name="txt_uan" type="text" id="txt_uan" size="10">

              /
              <input name="txt_nilai_uan" type="text" id="txt_nilai_uan" size="5"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">13</font></td>
            <td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nama
              Ayah</font></td>

            <td width="545"><input name="txt_nama_ayah" type="text" id="txt_nama_ayah" size="30"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pekerjaan</font></td>
            <td><input name="txt_pkrjaan_ayah" type="text" id="txt_pkrjaan_ayah" size="30"></td>
          </tr>
        </table></td>
    </tr>

    <tr>
      <td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">14</font></td>
            <td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nama
              Ibu</font></td>
            <td width="545"><input name="txt_nama_ibu" type="text" id="txt_nama_ibu" size="30"></td>
          </tr>
          <tr>
            <td>&nbsp;</td>

            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pekerjaan</font></td>
            <td><input name="txt_pkrjaan_ibu" type="text" id="txt_pkrjaan_ibu" size="30"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">15</font></td>

            <td width="197"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Alamat
              Orang Tua</font></td>
            <td width="544"><textarea name="txt_alamat_ortu" cols="42" id="txt_alamat_ortu"></textarea></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="38"><table width="790" border="0" align="center" cellpadding="3">
          <tr>
            <td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">16</font></td>

            <td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Telp
              Orang Tua</font></td>
            <td width="546"><input name="txt_telp_ortu" type="text" id="txt_telp_ortu" size="30"></td>
          </tr>
        </table></td>
    </tr>
    <tr>
      <td bgcolor="gray" height="37"><table width="790" border="0" align="center" cellpadding="1">
          <tr>
            <td width="25"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">17</font></td>

            <td width="200"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Sumber
              Info Pendaftaran</font></td>
            <td width="98" rowspan="2"><div align="left"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">A.
                Koran </font></div></td>
            <td width="176"> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_koran" value="Serambi Indonesia">
              Serambi Indonesia </font></td>
            <td colspan="2"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_koran" value="Harian Aceh">
              Harian Aceh</font></td>

          </tr>
          <tr>
            <td bgcolor="gray" height="22">&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_koran" value="Waspada">
              Waspada</font></td>
            <td width="114" valign="middle"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input type="radio" name="rd_koran" value="Lainnya">
              Lainnya &nbsp; &nbsp; &nbsp; </font></td>

            <td width="151"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="txt_koran" type="text" id="txt_koran" size="20">
              </font></td>
          </tr>
          <tr>
            <td bgcolor="gray" height="19">&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_radio" type="checkbox" id="chk_radio" value="1">
              Radio</font></td>

            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_spanduk" type="checkbox" id="chk_spanduk" value="1">
              Spanduk </font></td>
            <td colspan="2"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_presentasi" type="checkbox" id="chk_presentasi" value="1">
              Presentasi Daerah</font></td>
          </tr>
          <tr>
            <td bgcolor="gray" height="19">&nbsp;</td>

            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_brosur" type="checkbox" id="chk_brosur" value="1">
              Brosur</font></td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_sekolah" type="checkbox" id="chk_sekolah" value="1">
              Sekolah</font></td>
            <td colspan="2"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_bimbel" type="checkbox" id="chk_bimbel" value="1">

              Bimbingan Belajar</font></td>
          </tr>
          <tr>
            <td bgcolor="gray" height="22">&nbsp;</td>
            <td>&nbsp;</td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_poster" type="checkbox" id="chk_poster" value="1">
              Poster </font></td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_website" type="checkbox" id="chk_website" value="1">

              Website</font></td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="chk_lainnya" type="checkbox" id="chk_lainnya" value="1">
              Lainnya </font></td>
            <td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
              <input name="txt_info" type="text" id="txt_info" size="20">
              </font></td>
          </tr>
        </table></td>

    </tr>
    <tr>
      <td bgcolor="gray" height="119"><table width="790" border="0" align="center" cellpadding="1">
          <tr>
            <td width="21" height="111"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">18</font></td>
            <td width="205"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pilihan
              Program Studi</font></td>
            <td width="177"><table width="76%" border="0" cellpadding="1">
                <tr>
                  <td height="21"><div align="left"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pilihan
                      Pertama</font></div></td>

                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_1" value="Elektronika">
                    Elektronika</font></td>
                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_1" value="Komputer">

                    Komputer</font></td>
                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_1" value="Mekatronika">
                    Mekatronika</font></td>
                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_1" value="Akutansi">

                    Akutansi</font></td>
                </tr>
              </table></td>
            <td width="369"><table width="45%" border="0" cellpadding="1">
                <tr>
                  <td><div align="left"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pilihan
                      Kedua</font></div></td>
                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_2" value="Elektronika">

                    Elektronika</font></td>
                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_2" value="Komputer">
                    Komputer</font></td>
                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_2" value="Mekatronika">

                    Mekatronika</font></td>
                </tr>
                <tr>
                  <td> <font size="2" face="Verdana, Arial, Helvetica, sans-serif">
                    <input type="radio" name="rd_pil_2" value="Akutansi">
                    Akutansi</font></td>
                </tr>
              </table></td>

          </tr>
        </table></td>
    </tr>
  </table>
  <table width="823" border="0" align="center" cellpadding="3">
    <tr>
      <td width="745"><div align="right">
          <input name="btn_simpan" type="submit" id="btn_simpan" value="Simpan" >
        </div></td>

      <td width="54"><div align="right">
          <input type="reset" name='f' value="Reset">
        </div></td>
    </tr>
  </table>
  <p>&nbsp;</p>
</form>
</body>
</html>


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