FORMULIR BERLANGGANAN MARKET INFO
<form method="post" action="http://www.emailmeform.com/fid.php?formid=337688" enctype="multipart/form-data" accept-charset="UTF-8">
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<font face="Verdana" size="2" color="#000000">Form Trial dan/atau Berlangganan Market Info <br>
*) Wajib diisi</font>
 <div style="" id="mainmsg"> </div>

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 <td nowrap><font face="Verdana" size="2" color="#000000">Nama (Sesuai KTP)   *)</font></td>
 <td><input type="text" name="FieldData0" size="65"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">No. Identitas (KTP/SIM/dll)   *)</font></td>
 <td><input type="text" name="FieldData1" size="45"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">TTL/Tempat Tgl Lahir</font></td>
 <td><input type="text" name="FieldData2" size="45"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Jenis kelamin (L/P)</font></td>
 <td><input type="text" name="FieldData3" size="15"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Alamat (Sesuai KTP)   *)</font></td>
 <td><textarea name="FieldData4" cols="60" rows="10"></textarea><br> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Kota   *)</font></td>
 <td><input type="text" name="FieldData5" 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="FieldData6" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Negara</font></td>
 <td><input type="text" name="FieldData7" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Hanphone   *)</font></td>
 <td><input type="text" name="FieldData8" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Telephone   </font></td>
 <td><input type="text" name="FieldData9" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Email 1   *)</font></td>
 <td><input type="text" name="FieldData10" size="45"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Email 2</font></td>
 <td><input type="text" name="FieldData11" size="45"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">User ID</font></td>
 <td><input type="text" name="FieldData12" size="30"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Jenis Komunikasi (ISP)</font></td>
 <td><input type="text" name="FieldData13" size="60"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000">Catatan / Keterangan</font></td>
 <td><input type="text" name="FieldData14" size="60"> </td>
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 <td nowrap><font face="Verdana" size="2" color="#000000"></font></td>
 <td><input type="text" name="FieldData15" size="60"> </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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 <td align="right">
<input type="text" name="hida2" value="" maxlength="100" size="3" style="display : none;">
<input type="submit" class="btn" value="Send email" name="Submit">&nbsp; &nbsp; <input type="reset" class="btn" value="  Clear  " name="Clear"></td>
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<td colspan=2 align="center">
<br>
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</form>Happy Kurniawan <br>
http://safir78.wordpress.com <br>
prusafir78@yahoo.co.id <br>
0812 181 1378 / 021-3355 3037 <br>
<br>