- <?php
- include 'koneksi/koneksi.php';
- $nama = $_POST['nama'];
- $no_telp = $_POST['no_telp'];
- $email = $_POST['email'];
- $laporan = $_POST['laporan'];
- $status = "belum";
- $filename = $_FILES['foto']['name'];
- $ukuran = $_FILES['foto']['size'];
- } else {
- if($ukuran < 1044070) {
- $xx = $rand.'_'.$filename;
- INSERT INTO tb_laporan VALUES
- (
- NULL,'$nama','$no_telp','$email','$laporan','$xx','$tanggal','$status',NULL,NULL,NULL,NULL
- )"
- } else {
- }
- }
- }
- ?>
- <script src="assets/js-ui/external/jquery/jquery.js"></script>
- <script src="assets/js-ui/jquery-ui.js"></script>
- <link rel="stylesheet" href="assets/js-ui/jquery-ui.css"></script>
- <style type="text/css">
- .tanggal {
- position:static;
- width:32%;
- height: 30px;
- padding:6px 15px;
- border:1px solid #dbdbdb;
- -webkit-border-radius: 5px;
- -moz-border-radius: 5px;
- border-radius: 5px 5px 5px 5px;
- text-align: center;
- vertical-align:top;
- }
- .labelnya {
- width:25%;
- height: 30px;
- padding:6px 15px;
- background:#dbdbdb;
- border:1px solid #dbdbdb;
- -webkit-border-radius: 5px;
- -moz-border-radius: 5px;
- border-radius: 5px 0px 0px 5px;
- text-align: left;
- }
- .kolomnya {
- position:absolute;
- width:73%;
- height: 30px;
- padding:6px 15px;
- border:1px solid #dbdbdb;
- -webkit-border-radius: 5px;
- -moz-border-radius: 5px;
- border-radius: 0px 5px 5px 0px;
- text-align: left;
- }
- .buton {
- position:relative;
- width:200px;
- height: 30px;
- padding:6px 15px;
- border:1px solid #dbdbdb;
- -webkit-border-radius: 5px;
- -moz-border-radius: 5px;
- border-radius: 5px;
- text-align: center;
- }
- </style>
- <body id="page-top" class="theme-red">
- <div class="row clearfix">
- <div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
- <div class="card">
- <div class="header">
- <h2><b><center>Laporan / Informasi</center></b></h2>
- </div>
- <div class="body">
- <form action="" method="post" enctype="multipart/form-data" >
- <div class="control-group">
- <div class="control-group">
- <label class="control-label">Nama*</label>
- <div class="controls">
- <input type="text" class="form-control" name="nama" id="nama" required="required" placeholder="Masukan Nama">
- <span class="help-block"></span>
- </div>
- </div>
- <div class="control-group">
- <label class="control-label">No HP / WA AKTIF*</label>
- <div class="controls">
- <input type="number" class="form-control" name="no_telp" id="no_telp" required="required" placeholder="Masukan kontak">
- <span class="help-block"></span>
- </div>
- </div>
- <div class="control-group">
- <label class="control-label">Email*</label>
- <div class="controls">
- <input type="text" class="form-control" name="email" id="email" required="required" placeholder="Masukan email">
- <span class="help-block"></span>
- </div>
- </div>
- <div class="control-group">
- <div class="control-group">
- <label class="control-label">Isi Laporan / Informasi*</label>
- <div class="controls">
- <textarea type="text" class="form-control" name="laporan" id="laporan" required="required" placeholder="Masukan Laporan"></textarea>
- <span class="help-block"></span>
- </div>
- </div>
- <div class="control-group">
- <label class="control-label">Foto KTP/SIM*</label>
- <div class="controls">
- <input type="file" class="form-control" name="foto" id="foto" required="required">
- <span class="help-block"></span>
- </div>
- </div>
- Catatan :
- <p> - Semua informasi yang disampaikan diatas adalah
- benar adanya.</p>
- - Semua data dan informasi anda kami jaga
- kerahasiannya.
- <div class="buttons">
- <input type="submit" name="simpan" value="Simpan" class="btn btn-primary">
- <!-- <a href="cetak_data.php" class="btn btn-danger buton" type="submit" name ="submit" target="_blank">CETAK</a> -->
- </div>
- </form>
- </div>
- </div>
- </div>
- </div>
- </body>
- </html>
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