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<?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');
?>