Buat yang mau bergabung dapat cepat mendapat member, harap mengisi Formulir dengan lengkap.<form method="post" action="http://www.emailmeform.com/fid.php?formid=272829" enctype="multipart/form-data" accept-charset="UTF-8">
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<font face="Verdana" size="2" color="#000000">FORMULIR PENDAFTARAN ONLINE</font>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Nama</font></td>
 <td><input type="text" name="FieldData0" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">No. KTP / SIM</font></td>
 <td><input type="text" name="FieldData1" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Jenis Kelamin </font></td>
 <td><input type=checkbox name="FieldData2-0" value="L" id="check20"><font face="Verdana" size="2" color="#000000"><label for="check20">L</label></font><br><input type=checkbox name="FieldData2-1" value="P" id="check21"><font face="Verdana" size="2" color="#000000"><label for="check21">P</label></font><br> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Tanggal Lahir (dd/mm/yy)</font></td>
 <td><input type="text" name="FieldData3" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Alamat Surat</font></td>
 <td><textarea name="FieldData4" cols="30" rows="2"></textarea><br> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">RT</font></td>
 <td><input type="text" name="FieldData5" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">RW</font></td>
 <td><input type="text" name="FieldData6" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Kode POS</font></td>
 <td><input type="text" name="FieldData7" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Telepon</font></td>
 <td><input type="text" name="FieldData8" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Hp</font></td>
 <td><input type="text" name="FieldData9" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Suami / Istri</font></td>
 <td><input type="text" name="FieldData10" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Jumlah Anak</font></td>
 <td><input type="text" name="FieldData11" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Ahli Waris</font></td>
 <td><input type="text" name="FieldData12" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">No. Rekening</font></td>
 <td><input type="text" name="FieldData13" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Bank Rekening</font></td>
 <td><input type="text" name="FieldData14" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Atas Nama Rekening</font></td>
 <td><input type="text" name="FieldData15" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Kota</font></td>
 <td><input type="text" name="FieldData16" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Upline</font></td>
 <td><input type="text" name="FieldData17" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Sponsor</font></td>
 <td><input type="text" name="FieldData18" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Presenter</font></td>
 <td><input type="text" name="FieldData19" size="30"> </td>
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<td class="label" colspan="2"><font color="#FFFFFF" face="Verdana" size="2"><b>Image Verification</b></font></td>
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<td class="captcha" style="padding: 2px;" width="10"><img src="http://www.emailmeform.com/turing.php" id="captcha" alt="captcha"></td>
<td class="field" valign="top"><div><font color="#000000">Please enter the text from the image</font>:<br><input type="text" name="Turing" value="" maxlength="100" size="10">
 [ <a href="#" onclick=" document.getElementById('captcha').src = document.getElementById('captcha').src + '?' + (new Date()).getMilliseconds()">Refresh Image</a> ] [ <a href="http://www.emailmeform.com/?v=turing&amp;pt=popup" onClick="window.open('http://www.emailmeform.com/?v=turing&amp;pt=popup','_blank','width=400, height=500, left=' + (screen.width-450) + ', top=100');return false;">What's This?</a> ]</div>
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<input type="text" name="hida2" value="" maxlength="100" size="3" style="display : none;">
<input type="submit" class="btn" value="Daftar" name="Submit">&nbsp; &nbsp; <input type="reset" class="btn" value="  Clear  " name="Clear"></td>
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