<?php 
require_once(dirname(__FILE__).'/koneksi.php');
require_once(dirname(__FILE__).'/common/header.php');
?>
<br/>
<form class="well form-horizontal" action="cek_daftar.php" method="post"  id="contact_form">
<fieldset>
<legend>Member Registration</legend>
<div class="form-group">
  <label class="col-md-4 control-label">Nama</label>  
  <div class="col-md-4 inputGroupContainer">
  <div class="input-group">
  <span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
  <input  name="name" required placeholder="Isi Nama Anda" class="form-control"  type="text">
    </div>
  </div>
</div>
<div class="form-group">
  <label class="col-md-4 control-label">Alamat</label>  
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
        <span class="input-group-addon"><i class="glyphicon glyphicon-home"></i></span>
  <input name="address" required placeholder="Isi alamat Anda" class="form-control" type="text">
    </div>
  </div>
</div>
<div class="form-group">
  <label class="col-md-4 control-label">Hp #</label>
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
        <span class="input-group-addon"><i class="glyphicon glyphicon-earphone"></i></span>
  <input name="phone" required placeholder="Nomor Handphone" class="form-control" type="text">
    </div>
  </div>
</div>
<div class="form-group">
  <label class="col-md-4 control-label">Email </label>
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
        <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
  <input name="email" required placeholder="E-mail" class="form-control" type="email">
    </div>
  </div>
</div>
<div class="form-group">
  <label class="col-md-4 control-label">Username</label>  
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
        <span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
        <input name="username" required placeholder="Isi username anda" class="form-control"  type="text">
    </div>
  </div>
</div>
<div class="form-group">
  <label class="col-md-4 control-label">Password</label> 
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
    <span class="input-group-addon"><i class="glyphicon glyphicon-lock"></i></span>
    <input name="password" required placeholder="Password" class="form-control"  type="password">
    </div>
  </div>
</div> 
<div class="form-group">
  <label class="col-md-4 control-label">Ulangi Password</label> 
    <div class="col-md-4 inputGroupContainer">
    <div class="input-group">
    <span class="input-group-addon"><i class="glyphicon glyphicon-lock"></i></span>
    <input name="repass" required placeholder="Ulangi Password anda" class="form-control"  type="password">
    </div>
  </div>
</div> 
<div class="form-group">
  <label class="col-md-4 control-label"></label>
  <div class="col-md-4">
    <button type="submit" class="btn btn-warning"> Daftar <span class="glyphicon glyphicon-send"></span></button>
  </div>
</div>
</fieldset>
</form>
<?php
require_once(dirname(__FILE__).'/common/footer.php');
?>
