<form id="form1" method="post" action="/post.php" onsubmit="return valid_application();">
<table style="width:480px" border="0" cellspacing="0" cellpadding="4" align="center">
<tr valign="top">
<td colspan="3"><span class="required">(*) Kolom-kolom yang wajib diisikan</span> </td>
</tr>
<tr valign="top">
<td style="width:140px">Nama<span class="required">*</span></td>
<td style="width:20px">:</td>
<td><input type="text" class="input-txt" name="c_name" onfocus="doFocus(this);" onblur="doBlur(this);" /></td>
</tr>
<tr valign="top">
<td>Email<span class="required">*</span></td>
<td>:</td>
<td><input type="text" class="input-txt" name="c_email" onfocus="doFocus(this);" onblur="doBlur(this);" /></td>
</tr>
<tr valign="top">
<td>Jenis Kelamin</td>
<td>:</td>
<td>
<label><input type="radio" name="c_sex" value="Laki-laki" checked="checked" /> Laki-laki</label>
<label><input type="radio" name="c_sex" value="Perempuan" /> Perempuan</label>
</td>
</tr>
<tr valign="top">
<td>Tempat/tanggal lahir<span class="required">*</span></td>
<td>:</td>
<td>
<input type="text" class="input-txt" name="c_birthplace"
onfocus="doFocus(this);" onblur="doBlur(this);"
style="width: 100px;" />
/
<select name="c_birthdate" id="c_birthdate" size="1">
<option value="1"> 1</option>
<option value="2"> 2</option>
<option value="3"> 3</option>
<option value="4"> 4</option>
<option value="5"> 5</option>
<option value="6"> 6</option>
<option value="7"> 7</option>
<option value="8"> 8</option>
<option value="9"> 9</option>
<option value="10"> 10</option>
<option value="11"> 11</option>
<option value="12"> 12</option>
<option value="13"> 13</option>
<option value="14"> 14</option>
<option value="15"> 15</option>
<option value="16"> 16</option>
<option value="17"> 17</option>
<option value="18" selected> 18</option>
<option value="19"> 19</option>
<option value="20"> 20</option>
<option value="21"> 21</option>
<option value="22"> 22</option>
<option value="23"> 23</option>
<option value="24"> 24</option>
<option value="25"> 25</option>
<option value="26"> 26</option>
<option value="27"> 27</option>
<option value="28"> 28</option>
<option value="29"> 29</option>
<option value="30"> 30</option>
<option value="31"> 31</option>
</select><select name="c_birthmonth" id="c_birthmonth" size="1">
<option value="1"> 1</option>
<option value="2" selected> 2</option>
<option value="3"> 3</option>
<option value="4"> 4</option>
<option value="5"> 5</option>
<option value="6"> 6</option>
<option value="7"> 7</option>
<option value="8"> 8</option>
<option value="9"> 9</option>
<option value="10"> 10</option>
<option value="11"> 11</option>
<option value="12"> 12</option>
</select><select name="c_birthyear" id="c_birthyear" size="1">
<option value="1957"> 1957</option>
<option value="1958"> 1958</option>
<option value="1959"> 1959</option>
<option value="1960"> 1960</option>
<option value="1961"> 1961</option>
<option value="1962"> 1962</option>
<option value="1963"> 1963</option>
<option value="1964"> 1964</option>
<option value="1965"> 1965</option>
<option value="1966"> 1966</option>
<option value="1967"> 1967</option>
<option value="1968"> 1968</option>
<option value="1969"> 1969</option>
<option value="1970"> 1970</option>
<option value="1971"> 1971</option>
<option value="1972"> 1972</option>
<option value="1973"> 1973</option>
<option value="1974"> 1974</option>
<option value="1975"> 1975</option>
<option value="1976"> 1976</option>
<option value="1977"> 1977</option>
<option value="1978"> 1978</option>
<option value="1979"> 1979</option>
<option value="1980"> 1980</option>
<option value="1981"> 1981</option>
<option value="1982"> 1982</option>
<option value="1983"> 1983</option>
<option value="1984"> 1984</option>
<option value="1985"> 1985</option>
<option value="1986"> 1986</option>
<option value="1987"> 1987</option>
<option value="1988"> 1988</option>
<option value="1989"> 1989</option>
<option value="1990"> 1990</option>
<option value="1991"> 1991</option>
<option value="1992"> 1992</option>
<option value="1993"> 1993</option>
<option value="1994"> 1994</option>
<option value="1995" selected> 1995</option>
</select>
</td>
</tr>
<tr valign="top">
<td>Kartu Identitas<span class="required">*</span></td>
<td>:</td>
<td>
<select name="c_idcard_type" id="c_idcard_type" size="1">
<option value="KTP"> KTP</option>
<option value="SIM"> SIM</option>
<option value="LAINNYA"> Lainnya</option>
</select>
<label> No. </label>
<input type="text" class="input-txt" name="c_idcard_num"
onfocus="doFocus(this);" onblur="doBlur(this);"
style="width: 182px;" />
</td>
</tr>
<tr valign="top">
<td>Alamat (KTP)<span class="required">*</span></td>
<td>:</td>
<td><textarea name="c_address" rows="5" class="input-txt" onfocus="doFocus(this);" onblur="doBlur(this);"></textarea></td>
</tr>
<tr valign="top">
<td>Kota<span class="required">*</span></td>
<td>:</td>
<td><input type="text" class="input-txt" name="c_city" onfocus="doFocus(this);" onblur="doBlur(this);" /></td>
</tr>
<tr valign="top">
<td>No. Telp/Handphone<span class="required">*</span></td>
<td>:</td>
<td>
<input
type="text" class="input-txt" name="c_any_phone" onfocus="doFocus(this);" onblur="doBlur(this);"
onkeyup="this.value = this.value.replace(/[^\/\d]/g, '');" />
</td>
</tr>
<tr valign="top">
<td>Pekerjaan</td>
<td>:</td>
<td><select name="c_job" id="c_job" size="1">
<option value="Karyawan"> Karyawan</option>
<option value="Wiraswasta"> Wiraswasta</option>
<option value="Badan Usaha"> Badan Usaha</option>
<option value="Profesi"> Profesi</option>
<option value="Lainnya"> Lainnya</option>
</select></td>
</tr>
<tr valign="top">
<td>Nama Perusahaan</td>
<td>:</td>
<td><input type="text" class="input-txt" name="c_company" onfocus="doFocus(this);" onblur="doBlur(this);" /></td>
</tr>
<tr valign="top">
<td>Jabatan</td>
<td>:</td>
<td><input type="text" class="input-txt" name="c_company_pos" onfocus="doFocus(this);" onblur="doBlur(this);" /></td>
</tr>
<tr valign="top">
<td>Lama bekerja</td>
<td>:</td>
<td>
<input type="text" class="input-txt" name="c_jobperiod_year" maxlength="4"
onfocus="doFocus(this);" onblur="doBlur(this);"
style="width: 40px;" onkeyup="this.value = this.value.replace(/[^\/\d]/g, '');" />
<label> Tahun</label>
<input type="text" class="input-txt" name="c_jobperiod_month" maxlength="2"
onfocus="doFocus(this);" onblur="doBlur(this);"
style="width: 40px;" onkeyup="this.value = this.value.replace(/[^\/\d]/g, '');" />
<label> Bulan</label>
</td>
</tr>
<tr valign="top">
<td>Penghasilan Kotor per Bulan</td>
<td>:</td>
<td>
<select name="c_monthly_income" id="c_monthly_income" size="1">
<option value="< Rp 1,000,000"> < Rp 1,000,000</option>
<option value="Rp 1,000,000 - 2,000,000"> Rp 1,000,000 - 2.000.000</option>
<option value="Rp 2,000,000 - 3,000,000"> Rp 2,000,000 - 3,000,000</option>
<option value="Rp 3,000,000 - 5,000,000"> Rp 3,000,000 - 5,000,000</option>
<option value="> Rp 5,000,000"> > Rp 5,000,000</option>
</select>
</td>
</tr>
<tr valign="top">
<td>Tipe Kendaraan</td>
<td>:</td>
<td>
<select name="c_vehicle" id="c_vehicle" size="1">
<option value="Yamaha Mio"> Yamaha Mio</option>
<option value="Yamaha New Vega ZR-DB"> Yamaha New Vega ZR-DB</option>
<option value="Yamaha Mio CW "> Yamaha Mio CW </option>
<option value="Yamaha Jupiter ZX-15"> Yamaha Jupiter ZX-15</option>
<option value="Yamaha Mio Soul"> Yamaha Mio Soul</option>
<option value="Yamaha Jupiter Z - CW"> Yamaha Jupiter Z - CW</option>
<option value="Yamaha Jupiter MX 135LC-ATCW"> Yamaha Jupiter MX 135LC-ATCW</option>
<option value="Yamaha Xeon"> Yamaha Xeon</option>
<option value="Yamaha Lexam"> Yamaha Lexam</option>
<option value="Yamaha Jupiter MX 135LC-CW"> Yamaha Jupiter MX 135LC-CW</option>
<option value="Yamaha Byson"> Yamaha Byson</option>
<option value="Yamaha V-IXION"> Yamaha V-IXION</option>
<option value="Yamaha Scorpio ZCW"> Yamaha Scorpio ZCW</option>
<option value="Yamaha New Vega R"> Yamaha New Vega R</option>
<option value="Yamaha Vega-R DB SE"> Yamaha Vega-R DB SE</option>
<option value="Yamaha Mio SE Body Set"> Yamaha Mio SE Body Set</option>
<option value="Yamaha Mio SE Step Set"> Yamaha Mio SE Step Set</option>
<option value="Yamaha Mio Garnish"> Yamaha Mio Garnish</option>
<option value="Yamaha Mio Aero"> Yamaha Mio Aero</option>
<option value="Yamaha Mio CW SE Body Set"> Yamaha Mio CW SE Body Set</option>
<option value="Yamaha Mio CW SE Step Set"> Yamaha Mio CW SE Step Set</option>
<option value="Yamaha Mio CW - Garnish"> Yamaha Mio CW - Garnish</option>
<option value="Yamaha Mio CW - Aero"> Yamaha Mio CW - Aero</option>
<option value="Yamaha Mio Soul - Stylish"> Yamaha Mio Soul - Stylish</option>
<option value="Yamaha Mio Soul - Sporty"> Yamaha Mio Soul - Sporty</option>
<option value="Yamaha Nouvo Z"> Yamaha Nouvo Z</option>
<option value="Yamaha Jupiter-MX 135LC"> Yamaha Jupiter-MX 135LC</option>
<option value="Yamaha RX King"> Yamaha RX King</option>
<option value="Yamaha Scorpio Z"> Yamaha Scorpio Z</option>
</select>
</td>
</tr>
<tr valign="top">
<td>Uang muka</td>
<td>: Rp </td>
<td>
<input
type="text" class="input-txt" name="c_dp_gross"
onfocus="this.value=stripformat(this.value);doFocus(this);"
onblur="this.value=formatcurrency(this.value);doBlur(this);"
onkeyup="this.value = this.value.replace(/[^\/\d]/g, '');"
/>
</td>
</tr>
<tr valign="top">
<td colspan="3">
<p>
Untuk mencegah tindakan brute force, maka anda diwajibkan untuk memasukkan kode konfirmasi. Kode ditampilkan pada citra di bawah.
</p>
</td>
</tr>
<tr valign="top">
<td colspan="2"> </td>
<td>
<img src="http://www.baf.co.id/securicode.php" alt="" />
</td>
</tr>
<tr valign="top">
<td>Kode konfirmasi<span class="required">*</span></td>
<td>:</td>
<td>
<input type="text" class="input-txt" name="c_securicode" onfocus="doFocus(this);" onblur="doBlur(this);" />
<br />
<span>Masukkan kode konfirmasi tepat seperti yang terlihat pada gambar. Huruf besar dan kecil tidak berpengaruh, angka nol tidak pernah dimunculkan.</span>
</td>
</tr>
<tr valign="top">
<td colspan="3"> </td>
</tr>
<tr>
<td colspan="2"> </td>
<td>
<input type="hidden" name="section" value="credit_application" />
<input type="submit" name="btn_submit" value="Submit" />
<input type="reset" name="btn_reset" value="Reset" />
</td>
</tr>
</table>
<p> </p>
</form>
</div>
<script type="text/javascript">
var msg_name = 'Anda belum memberikan isian pada kolom NAMA!';
var msg_email = 'Anda belum memberikan isian pada kolom EMAIL!';
var msg_birthinfo = 'Anda belum memberikan isian pada kolom TEMPAT/TANGGAL LAHIR!';
var msg_idcard = 'Anda belum memberikan isian pada kolom KARTU IDENTITAS!';
var msg_address = 'Anda belum memberikan isian pada kolom ALAMAT!';
var msg_city = 'Anda belum memberikan isian pada kolom KOTA!';
var msg_phone = 'Anda belum memberikan isian pada kolom TELEPON!';
var msg_confirmation_code = 'Anda belum memberikan isian pada kolom KODE KONFIRMASI, mohon isikan kode yang tercetak pada citra!';
var length_confirmation_code = 6;
function stripformat(txt)
{
arr = txt.split(',');
return arr.join('');
}
</script>