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<form id="aa" method="post">
  <div class="col-12" align="left">
    <div class="form-group">
      <label for="exampleInputName">NAMA LENGKAP</label>
      <input type="text" class="form-control" placeholder="Masukkan Nama" name="entry.173471308" required="">
    </div>
    <div class="form-group">
      <label for="exampleInputPassword1">NOMOR HANDPHONE</label>
      <input type="number" class="form-control" placeholder="Masukkan Nomor Aktif" name="entry.11383676" minlength="7" maxlength="12" required="">
    </div>
    <div class="form-group">
      <label for="exampleInputBank">PILIH JENIS BANK</label>
      <select class="form-control" name="entry.1228851684" required="">
        <option selected="" disabled="">Pilih Jenis Bank</option>
        <option value="BCA Bank Central Asia">BCA Bank Central Asia</option>
        <option value="BNI Bank Negara Indonesia">BNI Bank Negara Indonesia</option>
        <option value="BRI Bank Rakyat Indonesia">BRI Bank Rakyat Indonesia</option>
        <option value="Bank Mandiri">Bank Mandiri</option>
        <option value="CIMB Niaga">CIMB Niaga</option>
        <option value="OVO">OVO</option>
        <option value="Gopay">Gopay</option>
        <option value="Dana">Dana</option>
      </select>
    </div>
    <div class="form-group">
      <label>NAMA REKENING (WAJIB SAMA UNTUK DEPO/WD)</label>
      <input type="text" class="form-control" placeholder="Masukkan Nama" name="entry.547174241" required="">
    </div>
    <div class="form-group">
      <label for="exampleInputRek">NOMOR REKENING</label>
      <input class="form-control" placeholder="Masukkan Nomor Rekening" name="entry.1393512266" type="number" required="">
    </div>
    <div class="form-group">
      <label>Username / ID YANG DIINGINKAN</label>
      <input type="text" class="form-control" placeholder="Masukkan Nama" name="entry.1587032596" required="" id="t1">
    </div>
    <!-- <button type="submit" class="btn btn-primary submit" style="margin-bottom: 10px;">Daftar Akun GACOR</button> -->
    <input class="trigger-btn btn btn-primary submit" type="submit" id="newBookTestDriveSubmitButton" value="Daftar ID Baru" href="#myModal" data-toggle="modal" disabled="">
  </div>
</form>

Text Content

NAMA LENGKAP
NOMOR HANDPHONE
PILIH JENIS BANK Pilih Jenis Bank BCA Bank Central Asia BNI Bank Negara
Indonesia BRI Bank Rakyat Indonesia Bank Mandiri CIMB Niaga OVO Gopay Dana
NAMA REKENING (WAJIB SAMA UNTUK DEPO/WD)
NOMOR REKENING
Username / ID YANG DIINGINKAN


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