tag:blogger.com,1999:blog-2060223303342938002024-02-22T02:20:31.670+08:00PASTI IBNU RUSYD TAMAN CICELYpasti ibnu rusydhttp://www.blogger.com/profile/14070571396382281744noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-206022330334293800.post-82261201239551428182011-10-08T20:49:00.000+08:002012-11-26T19:26:11.833+08:00PENDAFTARAN PELAJAR PASTI IBNU RUSYD TAMAN CICELY SESI 2013<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3SYlhSFm_iAtfPNNTxL5nt1-slUO8YIVbQwq9uulQJuy48OAbLtsZQhyphenhyphenCxbu-rE2cH8R5Yp9umGYf-u8htCxSf6g73Q08ObdsAbTA047vLKNFBCNIsqMidx8ANV-ZHqoGrRakGr5a5ahT/s1600/Banner2+pasti.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3SYlhSFm_iAtfPNNTxL5nt1-slUO8YIVbQwq9uulQJuy48OAbLtsZQhyphenhyphenCxbu-rE2cH8R5Yp9umGYf-u8htCxSf6g73Q08ObdsAbTA047vLKNFBCNIsqMidx8ANV-ZHqoGrRakGr5a5ahT/s400/Banner2+pasti.jpg" width="302" /></a></div>
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<form accept-charset="UTF-8" action="http://www.response-o-matic.com/mail.php" enctype="multipart/form-data" method="post">
<div>
<input id="acctid" name="acctid" type="hidden" value="6c8h8m564v1fb94o" /><br />
<input id="formid" name="formid" type="hidden" value="1001895" /></div>
<table border="0" cellpadding="5" cellspacing="5"><tbody>
<tr> <td valign="top"><br />
<b>PASTI Pilihan Anda</b></td> <td valign="top"><br />
<input id="field-719acea2d15a808_0" name="field-719acea2d15a808[]" type="checkbox" value="PASTI Ibnu Rusyd Taman Cicely" /> PASTI Ibnu Rusyd Taman Cicely<br />
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<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Nama Ibu / Bapa / Penjaga</b></td> <td valign="top"><br />
<input id="field-238fbcd1b0acf62" name="field-238fbcd1b0acf62" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>No. Kad Pengenalan Ibu / Bapa / Penjaga</b></td> <td valign="top"><br />
<input id="field-c2c5ad5fde99ff7" name="field-c2c5ad5fde99ff7" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>No. Telefon (R)</b></td> <td valign="top"><br />
<input id="field-9f44e1e64bdddd9" name="field-9f44e1e64bdddd9" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>No. Telefon (HP)</b></td> <td valign="top"><br />
<input id="field-88c3b90d764b754" name="field-88c3b90d764b754" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Alamat E-mel (Jika ada )</b></td> <td valign="top"><br />
<input id="field-b7d03dfb4728183" name="field-b7d03dfb4728183" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Alamat Kediaman</b></td> <td valign="top"><br />
<textarea cols="40" id="field-6343274a08c7629" name="field-6343274a08c7629" rows="6"></textarea><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Pekerjaan Ibu / Bapa / Penjaga</b></td> <td valign="top"><br />
<input id="field-3eae3431831bb6c" name="field-3eae3431831bb6c" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Nama Penuh Anak 1</b></td> <td valign="top"><br />
<input id="field-26d2e3895c4a46a" name="field-26d2e3895c4a46a" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Umur Anak 1</b></td> <td valign="top"><br />
<input id="field-24204cd9fd369ba" name="field-24204cd9fd369ba" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>No. Surat Lahir Anak 1</b></td> <td valign="top"><br />
<input id="field-e8764e3b91ddca1" name="field-e8764e3b91ddca1" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Kesihatan Anak 1</b></td> <td valign="top"><br />
<input id="field-2a894acfee92841_0" name="field-2a894acfee92841[]" type="checkbox" value="Sihat" /> Sihat<br />
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<input id="field-2a894acfee92841_1" name="field-2a894acfee92841[]" type="checkbox" value="Alahan" /> Alahan<br />
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<input id="field-2a894acfee92841_2" name="field-2a894acfee92841[]" type="checkbox" value="Berpenyakit" /> Berpenyakit<br />
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<input id="field-2a894acfee92841_3" name="field-2a894acfee92841[]" type="checkbox" value="Berpenyakit Kronik" /> Berpenyakit Kronik<br />
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<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Catatan</b></td> <td valign="top"><br />
<textarea cols="40" id="field-6a0ad7e54166ae0" name="field-6a0ad7e54166ae0" rows="6"></textarea><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Nama Penuh Anak 2</b></td> <td valign="top"><br />
<input id="name" name="name" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Umur Anak 2</b></td> <td valign="top"><br />
<input id="field-bfff7ae91a411ab" name="field-bfff7ae91a411ab" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>No. Surat Lahir Anak 2</b></td> <td valign="top"><br />
<input id="field-03a15edf662e87a" name="field-03a15edf662e87a" size="40" type="text" value="" /><br />
<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Kesihatan Anak 2</b></td> <td valign="top"><br />
<input id="field-4e7a8b18ac562ab_0" name="field-4e7a8b18ac562ab[]" type="checkbox" value="Sihat" /> Sihat<br />
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<input id="field-4e7a8b18ac562ab_1" name="field-4e7a8b18ac562ab[]" type="checkbox" value="Alahan" /> Alahan<br />
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<input id="field-4e7a8b18ac562ab_2" name="field-4e7a8b18ac562ab[]" type="checkbox" value="Berpenyakit" /> Berpenyakit<br />
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<input id="field-4e7a8b18ac562ab_3" name="field-4e7a8b18ac562ab[]" type="checkbox" value="Berpenyakit Kronik" /> Berpenyakit Kronik<br />
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<br /></td> </tr>
<tr> <td valign="top"><br />
<b>Catatan</b></td> <td valign="top"><br />
<textarea cols="40" id="field-f99783ac275017f" name="field-f99783ac275017f" rows="6"></textarea><br />
<br /></td> </tr>
<tr> <td align="center" colspan="2"><br />
<input type="submit" value=" Submit Form " /></td> </tr>
</tbody></table>
</form>
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