servicekendaraan.bagumum-kotakediri.com Open in urlscan Pro
5.181.216.129  Public Scan

Form analysis
1 forms found in the DOM

POST

<form class="py-2" id="formpost" method="POST">
  <input type="hidden" name="_token" value="5yqEDQ2bcgnxo8AVESg357eK18A2gGsbbDe2Xa76">
  <div class="form-group">
    <label for="formGroupExampleInput">Nama Lengkap</label>
    <div class="input-group date">
      <input type="text" name="nama_pendaftar" class="form-control" id="nama_pendaftar" placeholder="Nama Anda" required="required">
      <div class="input-group-append">
        <span class="input-group-text" id="basic-addon2">
          <i class="far fa-smile"></i>
        </span>
      </div>
    </div>
  </div>
  <div class="form-group">
    <label for="formGroupExampleInput">Email</label>
    <div class="input-group date">
      <input type="email" name="email_pendaftar" class="form-control" id="email_pendaftar" placeholder="Email Anda" required="required">
      <div class="input-group-append">
        <span class="input-group-text" id="basic-addon2">
          <i class="fas fa-envelope"></i>
        </span>
      </div>
    </div>
  </div>
  <div class="form-group">
    <label for="formGroupExampleInput">Nomor HP/Whatsapp</label>
    <div class="input-group date">
      <input type="number" name="nomor_pendaftar" class="form-control" id="nomor_pendaftar" placeholder="Nomor Whatsapp Anda" required="required">
      <div class="input-group-append">
        <span class="input-group-text" id="basic-addon2">
          <i class="fab fa-whatsapp"></i>
        </span>
      </div>
    </div>
  </div>
  <div class="form-group">
    <label for="formGroupExampleInput">Dinas/Bagian</label>
    <div class="input-group date">
      <input type="text" name="dinas_pendaftar" class="form-control" id="dinas_pendaftar" placeholder="Dinas/Bagian Anda" required="required">
      <div class="input-group-append">
        <span class="input-group-text" id="basic-addon2">
          <i class="fas fa-dice-d20"></i>
        </span>
      </div>
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-6">
      <label for="formGroupExampleInput">Jenis Kendaraan</label>
      <select class="form-control" name="jenis_kendaraan_id" id="jenis_kendaraan_id">
        <option value="">Pilih Jenis Kendaraan</option>
        <option value="1">Motor</option>
        <option value="2">Mobil</option>
      </select>
    </div>
    <div class="form-group col-6">
      <label for="formGroupExampleInput">Nama Kendaraan</label>
      <select class="form-control" name="nama_kendaraan_id" id="nama_kendaraan_id">
        <option value="">Pilih Nama Kendaraan</option>
      </select>
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-6">
      <label for="formGroupExampleInput">Plat Nomor</label>
      <div class="input-group date">
        <input type="text" name="plat_nomor" class="form-control" id="plat_nomor" placeholder="Plat Nomor Anda" required="required">
        <div class="input-group-append">
          <span class="input-group-text" id="basic-addon2">
            <i class="fas fa-address-card"></i>
          </span>
        </div>
      </div>
    </div>
    <div class="form-group col-6">
      <label for="formGroupExampleInput">Kilometer Kendaraan</label>
      <div class="input-group date">
        <input type="number" name="km_kendaraan" class="form-control" id="km_kendaraan" placeholder="Kilometer Motor Anda" required="required">
        <div class="input-group-append">
          <span class="input-group-text" id="basic-addon2">
            <i class="fas fa-tachometer-alt"></i>
          </span>
        </div>
      </div>
    </div>
  </div>
  <div class="form-group">
    <label for="formGroupExampleInput">Keluhan Kendaraan</label>
    <div class="input-group date">
      <textarea class="form-control" id="keluhan_kendaraan" rows="3"></textarea>
      <div class="input-group-append">
        <span class="input-group-text" id="basic-addon2">
          <i class="fas fa-closed-captioning"></i>
        </span>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col">
      <div class="form-group">
        <div class="input-group">
          <button class="btn btn-primary d-none" id="loading_butt" type="button" style="background-color: #6648B0;" disabled="">
            <span class="spinner-grow spinner-grow-sm" role="status" aria-hidden="true"></span> Loading... </button>
          <button type="button" id="acc" class="btn text-white" style="background-color: #6648B0;"><i class="fa fa-check"></i> Daftar Sekarang</button>
        </div>
      </div>
    </div>
  </div>
</form>

Text Content

Service Kendaraan
   
 * Service Kendaraan
 * Daftar Service

Form Pendaftaran Service Kendaraan

Nama Lengkap

Email

Nomor HP/Whatsapp

Dinas/Bagian

Jenis Kendaraan Pilih Jenis Kendaraan Motor Mobil
Nama Kendaraan Pilih Nama Kendaraan
Plat Nomor

Kilometer Kendaraan

Keluhan Kendaraan

Loading... Daftar Sekarang
© 2020 Pemerintah Kota Kediri


© 2020 Pemerintah Kota Kediri

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