@extends('layouts.app') @section('title','Form') @section('content') <section class="section"> <div class="section-header"> <h1>Formulir Pengajuan Legalisir Online</h1> <div class="section-header-breadcrumb"> <div class="breadcrumb-item"><a href="/">Dashboard</a></div> <div class="breadcrumb-item">Formulir</div> </div> </div> <div class="section-body"> <form class="needs-validation" novalidate=""> <div class="row"> <div class="col-12 col-md-8 col-lg-8"> <div class="card"> <div class="card-body"> <div class="section-title mt-0">Data Diri</div> <div class="form-group"> <label>Nama Lengkap</label> <input type="text" class="form-control" required="" placeholder="Ketik nama Anda di sini"> <div class="invalid-feedback">Mohon isikan nama Anda</div> </div> <div class="row"> <div class="col-6 form-group"> <label>N I M</label> <div class="input-group"> <div class="input-group-prepend"> <div class="input-group-text"> <i class="fas fa-graduation-cap"></i> </div> </div> <input type="number" class="form-control number" required="" placeholder="Masukan NIM Anda"> <div class="invalid-feedback">Mohon isikan NIM Anda</div> </div> </div> <div class="col-6 form-group"> <label>Nomor KTP / NIK</label> <div class="input-group"> <div class="input-group-prepend"> <div class="input-group-text"> <i class="fas fa-id-card"></i> </div> </div> <input type="number" class="form-control number" required="" placeholder="Masukan No. KTP / NIK Anda"> <div class="invalid-feedback">Mohon isikan NIK Anda</div> </div> </div> </div> <div class="row"> <div class="col-6 form-group"> <label>Nomor Telepon / Whatsapp</label> <div class="input-group"> <div class="input-group-prepend"> <div class="input-group-text"> <i class="fas fa-phone"></i> </div> </div> <input type="text" class="form-control phone-number" required="" placeholder="Contoh: 081234567890"> <div class="invalid-feedback">Mohon isikan nomor telepon/Whatsapp Anda</div> </div> </div> <div class="col-6 form-group"> <label>Email</label> <div class="input-group"> <div class="input-group-prepend"> <div class="input-group-text"> <i class="fas fa-envelope"></i> </div> </div> <input type="email" class="form-control email" required="" placeholder="Ketik Email Anda di sini"> <div class="invalid-feedback" >example@example.com, dll</div> </div> <!-- <div id="pwindicator" class="pwindicator"> <div class="bar"></div> <div class="label"></div> </div> --> </div> </div> <div class="row"> <div class="col-8 form-group"> <label>Alamat Lengkap</label> <div class="input-group"> <!-- <div class="input-group-prepend"> <div class="input-group-text"> <i class="fas fa-map-marker-alt"></i> </div> </div> --> <input type="text" class="form-control" required="" placeholder=""> <div class="invalid-feedback">Mohon isikan alamat lengkap Anda</div> </div> </div> <div class="col-4 form-group"> <label>Provinsi</label> <select class="form-control" required="" placeholder="Provinsi"> <option>Pilih...</option> <option>Option 2</option> <option>Option 3</option> </select> <div class="invalid-feedback">Pilih Provinsi tempat tinggal Anda</div> </div> </div> <div class="row"> <div class="col-4"> <div class="form-group"> <label>Kota / Kabupaten</label> <select class="form-control" required="Default" placeholder="Kecamatan"> <option>Pilih...</option> <option>Option 2</option> <option>Option 3</option> </select> <div class="invalid-feedback">Pilih Kota/Kabupaten tempat tinggal Anda</div> </div> </div> <div class="col-4"> <div class="form-group"> <label>Kecamatan</label> <select class="form-control" placeholder="Kota/Kabupaten"> <option>Pilih...</option> <option>Option 2</option> <option>Option 3</option> </select> <div class="invalid-feedback">Pilih Kecamatan tempat tinggal Anda</div> </div> </div> <div class="col-4"> <div class="form-group"> <label>Kode Pos</label> <input type="number" class="form-control number" required="" placeholder="Kode Pos"> <div class="invalid-feedback">Isikan Kode Pos yg sesuai</div> </div> </div> </div> <div class="card-footer text-right"> <button class="btn btn-primary mr-1" type="submit">Submit</button> <button class="btn btn-secondary" type="reset">Reset</button> </div> </div> </div> <!-- <div class="card"> <div class="card-body"> <div class="section-title mt-0">Upload File</div> <div class="row"> <div class="col-6"> <div class="form-group"> <label>Upload File Ijazah Asli</label> <input type="file" class="form-control"> </div> </div> <div class="col-6"> <div class="form-group"> <label>Upload File Swafoto Ijazah + KTP</label> <input type="file" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-6"> <div class="form-group"> <label>Upload File Transkrip Nilai Asli</label> <input type="file" class="form-control"> </div> </div> <div class="col-6"> <div class="form-group"> <label>Upload File Swafoto Transkrip Nilai + KTP</label> <input type="file" class="form-control"> </div> </div> </div> </div> </div> </div> --> </div> <div class="col-12 col-md-4 col-lg-4"> <div class="card"> <div class="card-body"> <div class="section-title mt-0">Layanan Pengambilan</div> <div class="form-group"> <div class="form-check form-check-inline"> <input class="form-check-input" type="radio" name="pickupservice" id="pickup1" value="ambilsendiri"> <label class="form-check-label" for="pickup1">Ambil Sendiri</label> </div> <div class="form-check form-check-inline ml-4"> <input class="form-check-input" type="radio" name="pickupservice" id="pickup2" value="jasapengiriman"> <label class="form-check-label" for="pickup2">Jasa Pengiriman</label> </div> </div> </div> </div> <!-- <div class="card"> <div class="card-body"> <div class="form-group"> <center> <img src="{{asset('assets/img/btn-logo.png')}}" alt="Logo BTN" height="100" weight="200"> </center> </div> </div> </div> --> </div> </div> <div class="row"> <div class="col-12 col-sm-8 col-md-8 col-lg-8"> <div class="card"> <div class="card-body"> <div class="section-title mt-0">Upload File</div> <div class="row"> <div class="col-6"> <div class="form-group"> <label>Upload File Ijazah Asli</label> <input type="file" class="form-control"> </div> </div> <div class="col-6"> <div class="form-group"> <label>Upload File Swafoto Ijazah + KTP</label> <input type="file" class="form-control"> </div> </div> </div> <div class="row"> <div class="col-6"> <div class="form-group"> <label>Upload File Transkrip Nilai Asli</label> <input type="file" class="form-control"> </div> </div> <div class="col-6"> <div class="form-group"> <label>Upload File Swafoto Transkrip Nilai + KTP</label> <input type="file" class="form-control"> </div> </div> </div> </div> </div> </div> </div> </div> </form> </div> </div> </section> @endsection