winfree-dev.codehive.id
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103.110.10.13
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URL:
https://winfree-dev.codehive.id/
Submission: On August 22 via api from US — Scanned from US
Submission: On August 22 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
<form class="space-y-4 md:space-y-6" novalidate="">
<div><label for="name" class="block mb-2 text-sm font-medium text-gray-900 dark:text-white">Nama lengkap</label><input type="text" name="name" id="name"
class="bg-gray-50 border border-gray-300 focus:outline-none text-gray-900 sm:text-sm rounded-lg focus:ring-primary focus:border-primary block w-full p-2.5 dark:bg-gray-700 dark:border-gray-600 dark:placeholder-gray-400 dark:text-white dark:focus:ring-primary-hover dark:focus:border-primary-hover"
placeholder="Nama lengkap" required=""></div>
<div><label for="mobile" class="block mb-2 text-sm font-medium text-gray-900 dark:text-white">Nomor telepon</label><input type="number" name="mobile" id="mobile"
class="bg-gray-50 border border-gray-300 focus:outline-none text-gray-900 sm:text-sm rounded-lg focus:ring-primary focus:border-primary block w-full p-2.5 dark:bg-gray-700 dark:border-gray-600 dark:placeholder-gray-400 dark:text-white dark:focus:ring-primary-hover dark:focus:border-primary-hover"
placeholder="08xx" required=""></div>
<div><label for="gender" class="block mb-2 text-sm font-medium text-gray-900 dark:text-white">Jenis Kelamin</label><select name="gender" id="gender"
class="bg-gray-50 border border-gray-300 focus:outline-none text-gray-900 sm:text-sm rounded-lg focus:ring-primary focus:border-primary block w-full p-2.5 dark:bg-gray-700 dark:border-gray-600 dark:placeholder-gray-400 dark:text-white dark:focus:ring-primary-hover dark:focus:border-primary-hover appearance-none"
required="">
<option value="" selected="">-- Pilih Jenis Kelamin --</option>
<option value="L">Laki - laki</option>
<option value="P">Perempuan</option>
</select></div>
<div><label for="dateOfBirth" class="block mb-2 text-sm font-medium text-gray-900 dark:text-white">Tanggal lahir</label><input type="date" name="dateOfBirth" id="dateOfBirth"
class="bg-gray-50 border border-gray-300 focus:outline-none text-gray-900 sm:text-sm rounded-lg focus:ring-primary focus:border-primary block w-full p-2.5 dark:bg-gray-700 dark:border-gray-600 dark:placeholder-gray-400 dark:text-white dark:focus:ring-primary-hover dark:focus:border-primary-hover"
placeholder="Tanggal lahir" required=""></div><input type="hidden" name="mac" value="69:73:ad:c0:9c:8d"><input type="hidden" name="ap_name" value="RW08_Kelurahan Kujangsari"><button
class="w-full text-white disabled:bg-orange-300 disabled:cursor-wait bg-primary hover:bg-primary-hover focus:ring-4 focus:outline-none focus:ring-orange-300 font-medium rounded-lg text-sm px-5 py-2.5 text-center dark:bg-primary dark:hover:bg-primary-hover dark:focus:ring-primary-hover undefined"
type="submit">Submit</button>
</form>Text Content
Nama lengkap Nomor telepon Jenis Kelamin-- Pilih Jenis Kelamin --Laki - lakiPerempuan Tanggal lahir Submit