Pendaftaran

<!-- Begin Freedback Form --> <!-- DO NOT EDIT YOUR FORM HERE, PLEASE LOG IN AND EDIT AT FREEDBACK.COM --> <form enctype="multipart/form-data" method="post" action="https://www.freedback.com/mail.php" accept-charset="UTF-8"> <div> <input type="hidden" name="acctid" id="acctid" value="93v564sqd53sch7w" /> <input type="hidden" name="formid" id="formid" value="694802" /> <input type="hidden" name="required_vars" id="required_vars" value="name,email,field-d2a8bf0db58f323,field-50b4f434ad3eb9e,field-1020a09c0a79872,field-0077d6230176baa" /> </div> <table cellspacing="5" cellpadding="5" border="0"> <tr> <td valign="top"> <strong>Nama:</strong> </td> <td valign="top"> <input type="text" name="name" id="name" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Alamat Email:</strong> </td> <td valign="top"> <input type="text" name="email" id="email" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>No Tel.Bimbit</strong> </td> <td valign="top"> <input type="text" name="field-d2a8bf0db58f323" id="field-d2a8bf0db58f323" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Nobor Kad Pengenalan</strong> </td> <td valign="top"> <input type="text" name="field-50b4f434ad3eb9e" id="field-50b4f434ad3eb9e" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Alamat</strong> </td> <td valign="top"> <textarea name="field-a6db544fdd7f5fe" id="field-a6db544fdd7f5fe" rows="6" cols="40"></textarea> </td> </tr> <tr> <td valign="top"> <strong>Nama Waris</strong> </td> <td valign="top"> <input type="text" name="field-51e9e5376973905" id="field-51e9e5376973905" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Nombor Kad Pengenalan</strong> </td> <td valign="top"> <input type="text" name="field-1020a09c0a79872" id="field-1020a09c0a79872" size="40" value="" /> </td> </tr> <tr> <td valign="top"> <strong>Hubungan Suami/Isteri</strong> </td> <td valign="top"> <input type="text" name="field-0077d6230176baa" id="field-0077d6230176baa" size="40" value="" /> </td> </tr> <tr> <td colspan="2" align="center"> <input type="submit" value=" Submit Form " /> </td> </tr> </table> </form> <br><center><font face="Arial, Helvetica" size="1"><b> Form provided by <a href="https://www.freedback.com">Freedback</a>. </b></font></center> <!-- End Freedback Form -->