BIODATA TIRTOMOYO ONLINER<form method="post" action="http://www.emailmeform.com/fid.php?formid=73521" enctype="multipart/form-data" accept-charset="UTF-8">
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<font face="Verdana" size="2" color="#000000">mendatakan secara statistik kunjungan di Tirtomoyo Online sebagai alat ukur penilaian berdasarkan karakteristik user/pengguna jasa internet oleh warga tirtomoyo di seluruh pelosok dunia.</font>
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 <td><font face="Verdana" size="2" color="#000000">Nama </font></td>
 <td><input type="text" name="FieldData0" size="30"> </td>
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 <td><font face="Verdana" size="2" color="#000000">Desa Asal </font></td>
 <td><select name="FieldData1"><option value=""></option><option value="Tanjungsari">Tanjungsari</option><option value="Sendangmulyo">Sendangmulyo</option><option value="Arjosari">Arjosari</option><option value="Tirtomoyo">Tirtomoyo</option><option value="Banyakprodo">Banyakprodo</option><option value="Hargantoro">Hargantoro</option><option value="Wiroko">Wiroko</option><option value="Dlepih">Dlepih</option><option value="Sukoharjo">Sukoharjo</option><option value="Hargosari">Hargosari</option><option value="Hargorejo">Hargorejo</option><option value="Girirejo">Girirejo</option><option value="Genengharjo">Genengharjo</option><option value="Sidorejo">Sidorejo</option><option value="Lain Kecamatan

">Lain Kecamatan

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 <td><font face="Verdana" size="2" color="#000000">Tahun Lahir & Hobi </font></td>
 <td><input type="text" name="FieldData2" size="30"> </td>
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 <td><font face="Verdana" size="2" color="#000000">SMTP &Thn lulus </font></td>
 <td><input type="text" name="FieldData3" size="30"> </td>
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 <td><font face="Verdana" size="2" color="#000000">SMTA &Thn lulus </font></td>
 <td><input type="text" name="FieldData4" size="30"> </td>
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 <td><font face="Verdana" size="2" color="#000000">Akademi/Univ. & Thn lulus </font></td>
 <td><input type="text" name="FieldData5" size="30"> </td>
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 <td><font face="Verdana" size="2" color="#000000">Alamat Email </font></td>
 <td><input type="text" name="FieldData6" size="50"> </td>
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 <td><font face="Verdana" size="2" color="#000000">Instansi Kerja </font></td>
 <td><input type="text" name="FieldData7" size="50"> </td>
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 <td><font face="Verdana" size="2" color="#000000">Kota </font></td>
 <td><input type="text" name="FieldData8" size="30"> </td>
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 <td><font face="Verdana" size="2" color="#000000">Foto </font></td>
 <td><input type="file" name="FieldData9" value="" size="60"> </td>
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<td id="captcha_table_header_td"class="label" colspan="2"><font color="#FFFFFF" face="Verdana" size="2"><b>Image Verification</b></font></td>
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<td id="captcha_table_img_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&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="Send email" name="Submit">&nbsp; &nbsp; <input type="reset" class="btn" value="  Clear  " name="Clear"></td>
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