<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>Praktikum PHP 4</title>
</head>
<body>
<form action="script.php" name="form1" method="post">
<table border="0" width="500" height="300" Style='border-radius:10px;border-color:white;'>
<tr>
<td colspan="3"><b>DATA DIRI</b></td>
</tr>
<tr>
<td> Nama Lengkap </td>
<td width="10"><center>:</center></td>
<td><input type='text' name="nama"></td>
</tr>
<tr>
<td> Email </td>
<td><center>:</center></td>
<td><input type='text' name="email"></td>
</tr>
<tr>
<td> Nama Panggilan</td>
<td><center>:</center></td>
<td>
<input type="radio" value="L" name="gender"/>
Laki-Laki
<input type="radio" value="P" name="gender"/>
Perempuan
</td>
</tr>
<tr>
<td>Tempat Lahir</td>
<td><center>:</center></td>
<td><input type='text' name="tempat"></td>
</tr>
<tr>
<td>Tanggal Lahir</td>
<td><center>:</center></td>
<td>
<?php
$bulan=array("Januari" ,"Februari", " Maret" ,"April", "Mei", "Juni", "Juli", "Agustus", "September", "Oktober", "November", "Desember");
echo '<select name="hari">';
$hari=1;
while($hari<=31) {
echo "<option value='$hari'>$hari</option>";
$hari++;
}
echo '</select>';
echo '<select name="bulan">';
$jumlah=count($bulan);
for($i=0; $i<$jumlah ; $i++){
echo '<option value="'.$bulan[$i].'">'.$bulan[$i].'</option>';
}
echo '</select>';
echo '<select name="tahun">';
for($tahun=1995; $tahun<2010; $tahun++){
echo "<option value='$tahun'>$tahun</option>";
}
echo '</option>';
?>
</td>
</tr>
<tr>
<td>Umur</td>
<td><center>:</center></td>
<td>
<select name="umur" >
<option value="0-29">Di bawah 30 tahun</option>
<option value="30-60">Antara 30 s/d 60 tahun</option>
<option value="60++">Di atas 60 tahun</option>
</select>
</td>
</tr>
<tr>
<td>Komentar</td>
<td><center>:</center></td>
<td>
<textarea cols="28" rows="4" name="komentar"></textarea>
</td>
</tr>
<tr>
<td colspan="3"><center>
<button type="submit" name="submit">Submit</button>
<button type="reset" value="Refresh" ONCLICK="history.go(0)">Reset</button>
</center>
</td>
</tr>
</table>
</form>
</body>
</html>