dpw.jkiinjilkerajaan.org Open in urlscan Pro
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Form analysis
1 forms found in the DOM

POST /index.php

<form role="form" action="/index.php " method="post">
  <div class="form-group">
    <label for="nama">Nama <span style="color: #FF2424;font-size: 10pt">* </span></label>
    <input type="text" class="form-control" id="nama" name="nama" placeholder="Nama" required="">
  </div>
  <div class="form-group">
    <label for="no_wa">Tanggal Lahir<span style="color: #FF2424;font-size: 8pt">* </span></label>
    <br>
    <select class="col-xs-4 col-md-4" name="tgl_lhr" id="tgl_lhr">
      <option value="0">- Tanggal* -</option>
      <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">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 class="col-xs-4 col-md-4" name="bln_lhr" id="bln_lhr">
      <option value="0">- Bulan* -</option>
      <option value="1">Januari</option>
      <option value="2">Februari</option>
      <option value="3">Maret</option>
      <option value="4">April</option>
      <option value="5">Mei</option>
      <option value="6">Juni</option>
      <option value="7">Juli</option>
      <option value="8">Agustus</option>
      <option value="9">September</option>
      <option value="10">Oktober</option>
      <option value="11">November</option>
      <option value="12">Desember</option>
    </select>
    <select class="col-xs-4 col-md-4" name="thn_lhr" id="thn_lhr">
      <option value="0">- Tahun* -</option>
      <option value="1940">1940</option>
      <option value="1941">1941</option>
      <option value="1942">1942</option>
      <option value="1943">1943</option>
      <option value="1944">1944</option>
      <option value="1945">1945</option>
      <option value="1946">1946</option>
      <option value="1947">1947</option>
      <option value="1948">1948</option>
      <option value="1949">1949</option>
      <option value="1950">1950</option>
      <option value="1951">1951</option>
      <option value="1952">1952</option>
      <option value="1953">1953</option>
      <option value="1954">1954</option>
      <option value="1955">1955</option>
      <option value="1956">1956</option>
      <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">1995</option>
      <option value="1996">1996</option>
      <option value="1997">1997</option>
      <option value="1998">1998</option>
      <option value="1999">1999</option>
      <option value="2000">2000</option>
      <option value="2001">2001</option>
      <option value="2002">2002</option>
      <option value="2003">2003</option>
      <option value="2004">2004</option>
      <option value="2005">2005</option>
      <option value="2006">2006</option>
      <option value="2007">2007</option>
      <option value="2008">2008</option>
      <option value="2009">2009</option>
      <option value="2010">2010</option>
      <option value="2011">2011</option>
      <option value="2012">2012</option>
      <option value="2013">2013</option>
      <option value="2014">2014</option>
      <option value="2015">2015</option>
      <option value="2016">2016</option>
      <option value="2017">2017</option>
      <option value="2018">2018</option>
      <option value="2019">2019</option>
      <option value="2020">2020</option>
      <option value="2021">2021</option>
      <option value="2022">2022</option>
      <option value="2023">2023</option>
      <option value="2024">2024</option>
    </select>
  </div> <br>
  <div class="form-group">
    <label for="nama">Alamat <span style="color: #FF2424;font-size: 10pt">* </span></label>
    <input type="text" class="form-control" id="nama" name="nama" placeholder="Alamat" required="">
  </div>
  <div class="form-group">
    <label for="no_wa">Nomer WA <span style="color: #FF2424;font-size: 8pt">*</span></label>
    <input type="tel" class="form-control" id="no_wa" placeholder="Nomer WA Cth 081234567" name="no_wa" required="">
  </div>
  <div class="form-group">
    <label for="nama">NIJ <span style="color: #FF2424;font-size: 10pt">* </span></label>
    <input type="tel" class="form-control" id="nama" name="nama" placeholder="NIJ" required="">
  </div>
  <div class="form-group">
    <label for="nama">MPP <span style="color: #FF2424;font-size: 10pt">* </span></label>
    <input type="text" class="form-control" id="nama" name="nama" placeholder="MPP" required="">
  </div>
  <div class="form-group">
    <label for="no_wa">Baptis Roh<span style="color: #FF2424;font-size: 8pt">* </span></label>
    <br>
    <select class="col-xs-12 col-md-12" name="tgl_lhr" id="tgl_lhr">
      <option value="0">- Mohon Dipilih* -</option>
      <option value="1">Sudah</option>
      <option value="2">Belum</option>
    </select>
  </div> <br>
  <div class="form-group">
    <label for="no_wa">Baptis Air<span style="color: #FF2424;font-size: 8pt">* </span></label>
    <br>
    <select class="col-xs-12 col-md-12" name="tgl_lhr" id="tgl_lhr">
      <option value="0">- Mohon Dipilih* -</option>
      <option value="1">Sudah</option>
      <option value="2">Belum</option>
    </select>
  </div> <br>
  <div class="form-group">
    <label for="nama">Lahir Baru <span style="color: #FF2424;font-size: 10pt">* </span></label>
    <input type="text" class="form-control" id="nama" name="nama" placeholder="Lahir Baru" required="">
  </div>
  <div class="form-group">
    <label for="nama">Kesaksian <span style="color: #FF2424;font-size: 10pt">* </span></label>
    <br>
    <textarea class="col-xs-12 col-md-12" rows="5" cols="60" name="description">Kesaksian...</textarea>
  </div> <br> . <br>
  <button type="submit" class="btn btn-primary btn-block" name="ikut_kebaktian">Daftar</button>
</form>

Text Content

DATA PEMUSIK DPW | JKI INJIL KERAJAAN

Nama *
Tanggal Lahir*
- Tanggal* - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
26 27 28 29 30 31 - Bulan* - Januari Februari Maret April Mei Juni Juli Agustus
September Oktober November Desember - Tahun*
-1940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024

Alamat *
Nomer WA *
NIJ *
MPP *
Baptis Roh*
- Mohon Dipilih* - Sudah Belum

Baptis Air*
- Mohon Dipilih* - Sudah Belum

Lahir Baru *
Kesaksian *
Kesaksian...

.
Daftar