<link rel="stylesheet" type="text/css" href="http://www.emailmeform.com/builder/styles/dynamic.php?t=post" />
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<script type="text/javascript" src="http://www.emailmeform.com/builder/js/dynamic.php?t=post&t2=0&use_CDN=true"></script>
<div id="emf-container-outer">
<div id="emf-container">
<div id="emf-logo">
<a>EmailMeForm</a>
</div>
<form id="emf-form" class="topLabel" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/7zre918pa5a4Dv0kY" name="emf-form">
<div id="emf-form-instruction" class="emf-head-widget">
<div id="emf-form-title" class="emf-bold">
Menjadi Reseller
</div>
<div id="emf-form-description">
Jika, anda ingin bekerja sama dengan perusahaan kami.<br />
silahkan isi form berikut. mudah, simple, dan menguntungkan
</div>
</div>
<ul>
<li id="emf-li-0" class="emf-li-field emf-field-text data_container" style="text-align:left">
<label class="emf-label-desc" for="element_0">Nama <span>*</span></label>
<div class="emf-div-field">
<input id="element_0" name="element_0" value="" size="30" type="text" class="validate[required]" />
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-1" class="emf-li-field emf-field-email data_container" style="text-align:left">
<label class="emf-label-desc" for="element_1">Email</label>
<div class="emf-div-field">
<input id="element_1" name="element_1" class="validate[optional,custom[email]]" value="" size="30" type="text" />
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-2" class="emf-li-field emf-field-phone data_container" style="text-align:left">
<label class="emf-label-desc" for="element_2">Phone <span>*</span></label>
<div class="emf-div-field">
<input id="element_2" name="element_2" class="validate[required,custom[telephone]]" value="+62" size="30" type="text" />
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-3" class="emf-li-field emf-field-address data_container" style="text-align:left">
<label class="emf-label-desc" for="element_3">Alamat</label>
<div class="emf-div-field">
<div style="width:99%;">
<span class="emf-full emf-field-address-addr1"><input type="text" value="" id="element_3_1" name="element_3[]" class="emf-full validate[optional]" /> <label for="element_3_1" class=
"emf-bottom-label">Street Address</label></span> <span class="emf-full emf-field-address-addr2"><input type="text" value="" id="element_3_2" name="element_3[]" class=
"emf-full validate[optional]" /> <label for="element_3_2" class="emf-bottom-label">Address Line 2</label></span> <span class="emf-left emf-half emf-field-address-city"><input type=
"text" value="" id="element_3_3" name="element_3[]" class="emf-full validate[optional]" /> <label for="element_3_3" class="emf-bottom-label">City</label></span> <span class=
"emf-right emf-half emf-field-address-state"><input type="text" value="" id="element_3_4" name="element_3[]" class="emf-full validate[optional]" /> <label for="element_3_4" class=
"emf-bottom-label">State / Province / Region</label></span> <span class="emf-left emf-half emf-field-address-zipcode"><input type="text" value="" id="element_3_5" name="element_3[]"
class="emf-full validate[optional]" /> <label for="element_3_5" class="emf-bottom-label">Postal / Zip Code</label></span> <span class=
"emf-right emf-half emf-field-address-country"><select id="element_3_6" name="element_3[]" class="emf-address validate[optional]">
<optgroup label="North America">
<option value="Antigua and Barbuda">
Antigua and Barbuda
</option>
<option value="Aruba">
Aruba
</option>
<option value="Bahamas">
Bahamas
</option>
<option value="Barbados">
Barbados
</option>
<option value="Belize">
Belize
</option>
<option value="Canada">
Canada
</option>
<option value="Cook Islands">
Cook Islands
</option>
<option value="Costa Rica">
Costa Rica
</option>
<option value="Cuba">
Cuba
</option>
<option value="Dominica">
Dominica
</option>
<option value="Dominican Republic">
Dominican Republic
</option>
<option value="El Salvador">
El Salvador
</option>
<option value="Grenada">
Grenada
</option>
<option value="Guatemala">
Guatemala
</option>
<option value="Haiti">
Haiti
</option>
<option value="Honduras">
Honduras
</option>
<option value="Jamaica">
Jamaica
</option>
<option value="Mexico">
Mexico
</option>
<option value="Netherlands Antilles">
Netherlands Antilles
</option>
<option value="Nicaragua">
Nicaragua
</option>
<option value="Panama ">
Panama
</option>
<option value="Puerto Rico ">
Puerto Rico
</option>
<option value="Saint Kitts and Nevis">
Saint Kitts and Nevis
</option>
<option value="Saint Lucia">
Saint Lucia
</option>
<option value="Saint Vincent and the Grenadines">
Saint Vincent and the Grenadines
</option>
<option value="Trinidad and Tobago">
Trinidad and Tobago
</option>
<option value="United States">
United States
</option>
</optgroup>
<optgroup label="South America">
<option value="Argentina">
Argentina
</option>
<option value="Bolivia">
Bolivia
</option>
<option value="Brazil">
Brazil
</option>
<option value="Chile">
Chile
</option>
<option value="Colombia">
Colombia
</option>
<option value="Ecuador">
Ecuador
</option>
<option value="Guyana">
Guyana
</option>
<option value="Paraguay">
Paraguay
</option>
<option value="Peru">
Peru
</option>
<option value="Suriname">
Suriname
</option>
<option value="Uruguay">
Uruguay
</option>
<option value="Venezuela">
Venezuela
</option>
</optgroup>
<optgroup label="Europe">
<option value="Albania">
Albania
</option>
<option value="Andorra">
Andorra
</option>
<option value="Armenia">
Armenia
</option>
<option value="Austria">
Austria
</option>
<option value="Azerbaijan">
Azerbaijan
</option>
<option value="Belarus">
Belarus
</option>
<option value="Belgium">
Belgium
</option>
<option value="Bosnia and Herzegovina">
Bosnia and Herzegovina
</option>
<option value="Bulgaria">
Bulgaria
</option>
<option value="Croatia">
Croatia
</option>
<option value="Cyprus">
Cyprus
</option>
<option value="Czech Republic">
Czech Republic
</option>
<option value="Denmark">
Denmark
</option>
<option value="Estonia">
Estonia
</option>
<option value="Faroe Islands">
Faroe Islands
</option>
<option value="Finland">
Finland
</option>
<option value="France">
France
</option>
<option value="Georgia">
Georgia
</option>
<option value="Germany">
Germany
</option>
<option value="Greece">
Greece
</option>
<option value="Hungary">
Hungary
</option>
<option value="Iceland">
Iceland
</option>
<option value="Ireland">
Ireland
</option>
<option value="Italy">
Italy
</option>
<option value="Latvia">
Latvia
</option>
<option value="Liechtenstein">
Liechtenstein
</option>
<option value="Lithuania">
Lithuania
</option>
<option value="Luxembourg">
Luxembourg
</option>
<option value="Macedonia">
Macedonia
</option>
<option value="Malta">
Malta
</option>
<option value="Moldova">
Moldova
</option>
<option value="Monaco">
Monaco
</option>
<option value="Montenegro">
Montenegro
</option>
<option value="Netherlands">
Netherlands
</option>
<option value="Norway">
Norway
</option>
<option value="Poland">
Poland
</option>
<option value="Portugal">
Portugal
</option>
<option value="Romania">
Romania
</option>
<option value="San Marino">
San Marino
</option>
<option value="Serbia">
Serbia
</option>
<option value="Slovakia">
Slovakia
</option>
<option value="Slovenia">
Slovenia
</option>
<option value="Spain">
Spain
</option>
<option value="Sweden">
Sweden
</option>
<option value="Switzerland">
Switzerland
</option>
<option value="Ukraine">
Ukraine
</option>
<option value="United Kingdom">
United Kingdom
</option>
<option value="Vatican City">
Vatican City
</option>
</optgroup>
<optgroup label="Asia">
<option value="Afghanistan">
Afghanistan
</option>
<option value="Bahrain">
Bahrain
</option>
<option value="Bangladesh">
Bangladesh
</option>
<option value="Bhutan">
Bhutan
</option>
<option value="Brunei Darussalam">
Brunei Darussalam
</option>
<option value="Myanmar">
Myanmar
</option>
<option value="Cambodia">
Cambodia
</option>
<option value="China">
China
</option>
<option value="East Timor">
East Timor
</option>
<option value="Hong Kong">
Hong Kong
</option>
<option value="India">
India
</option>
<option value="Indonesia">
Indonesia
</option>
<option value="Iran">
Iran
</option>
<option value="Iraq">
Iraq
</option>
<option value="Israel">
Israel
</option>
<option value="Japan">
Japan
</option>
<option value="Jordan">
Jordan
</option>
<option value="Kazakhstan">
Kazakhstan
</option>
<option value="North Korea">
North Korea
</option>
<option value="South Korea">
South Korea
</option>
<option value="Kuwait">
Kuwait
</option>
<option value="Kyrgyzstan">
Kyrgyzstan
</option>
<option value="Laos">
Laos
</option>
<option value="Lebanon">
Lebanon
</option>
<option value="Malaysia">
Malaysia
</option>
<option value="Maldives">
Maldives
</option>
<option value="Mongolia">
Mongolia
</option>
<option value="Nepal">
Nepal
</option>
<option value="Oman">
Oman
</option>
<option value="Pakistan">
Pakistan
</option>
<option value="Palestine">
Palestine
</option>
<option value="Philippines">
Philippines
</option>
<option value="Qatar">
Qatar
</option>
<option value="Russia">
Russia
</option>
<option value="Saudi Arabia">
Saudi Arabia
</option>
<option value="Singapore">
Singapore
</option>
<option value="Sri Lanka">
Sri Lanka
</option>
<option value="Syria">
Syria
</option>
<option value="Taiwan">
Taiwan
</option>
<option value="Tajikistan">
Tajikistan
</option>
<option value="Thailand">
Thailand
</option>
<option value="Turkey">
Turkey
</option>
<option value="Turkmenistan">
Turkmenistan
</option>
<option value="United Arab Emirates">
United Arab Emirates
</option>
<option value="Uzbekistan">
Uzbekistan
</option>
<option value="Vietnam">
Vietnam
</option>
<option value="Yemen">
Yemen
</option>
</optgroup>
<optgroup label="Oceania">
<option value="Australia">
Australia
</option>
<option value="Fiji">
Fiji
</option>
<option value="Kiribati">
Kiribati
</option>
<option value="Marshall Islands">
Marshall Islands
</option>
<option value="Micronesia">
Micronesia
</option>
<option value="Nauru">
Nauru
</option>
<option value="New Zealand">
New Zealand
</option>
<option value="Palau">
Palau
</option>
<option value="Papua New Guinea">
Papua New Guinea
</option>
<option value="Samoa">
Samoa
</option>
<option value="Solomon Islands">
Solomon Islands
</option>
<option value="Tonga">
Tonga
</option>
<option value="Tuvalu">
Tuvalu
</option>
<option value="Vanuatu">
Vanuatu
</option>
</optgroup>
<optgroup label="Africa">
<option value="Algeria">
Algeria
</option>
<option value="Angola">
Angola
</option>
<option value="Benin">
Benin
</option>
<option value="Botswana">
Botswana
</option>
<option value="Burkina Faso">
Burkina Faso
</option>
<option value="Burundi">
Burundi
</option>
<option value="Cameroon">
Cameroon
</option>
<option value="Cape Verde">
Cape Verde
</option>
<option value="Central African Republic">
Central African Republic
</option>
<option value="Chad">
Chad
</option>
<option value="Comoros">
Comoros
</option>
<option value="Democratic Republic of the Congo">
Democratic Republic of the Congo
</option>
<option value="Republic of the Congo">
Republic of the Congo
</option>
<option value="Djibouti">
Djibouti
</option>
<option value="Egypt">
Egypt
</option>
<option value="Equatorial Guinea">
Equatorial Guinea
</option>
<option value="Eritrea">
Eritrea
</option>
<option value="Ethiopia">
Ethiopia
</option>
<option value="Gabon">
Gabon
</option>
<option value="Gambia">
Gambia
</option>
<option value="Ghana">
Ghana
</option>
<option value="Gibraltar">
Gibraltar
</option>
<option value="Guinea">
Guinea
</option>
<option value="Guinea-Bissau">
Guinea-Bissau
</option>
<option value="Cote d'Ivoire">
Cote d'Ivoire
</option>
<option value="Kenya">
Kenya
</option>
<option value="Lesotho">
Lesotho
</option>
<option value="Liberia">
Liberia
</option>
<option value="Libya">
Libya
</option>
<option value="Madagascar">
Madagascar
</option>
<option value="Malawi">
Malawi
</option>
<option value="Mali">
Mali
</option>
<option value="Mauritania">
Mauritania
</option>
<option value="Mauritius">
Mauritius
</option>
<option value="Morocco">
Morocco
</option>
<option value="Mozambique">
Mozambique
</option>
<option value="Namibia">
Namibia
</option>
<option value="Niger">
Niger
</option>
<option value="Nigeria">
Nigeria
</option>
<option value="Rwanda">
Rwanda
</option>
<option value="Sao Tome and Principe">
Sao Tome and Principe
</option>
<option value="Senegal">
Senegal
</option>
<option value="Seychelles">
Seychelles
</option>
<option value="Sierra Leone">
Sierra Leone
</option>
<option value="Somalia">
Somalia
</option>
<option value="South Africa">
South Africa
</option>
<option value="Sudan">
Sudan
</option>
<option value="Swaziland">
Swaziland
</option>
<option value="United Republic of Tanzania">
United Republic of Tanzania
</option>
<option value="Togo">
Togo
</option>
<option value="Tunisia">
Tunisia
</option>
<option value="Uganda">
Uganda
</option>
<option value="Zambia">
Zambia
</option>
<option value="Zimbabwe">
Zimbabwe
</option>
</optgroup>
</select> <label for="element_3_6" class="emf-bottom-label">Country</label></span>
<div class="emf-clear"></div>
</div>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-4" class="emf-li-field emf-field-text data_container" style="text-align:left">
<label class="emf-label-desc" for="element_4">Perusahaan <span>*</span></label>
<div class="emf-div-field">
<input id="element_4" name="element_4" value="" size="30" type="text" class="validate[required]" />
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-5" class="emf-li-field emf-field-textarea data_container" style="text-align:left">
<label class="emf-label-desc" for="element_5">Alamat Reseller <span>*</span></label>
<div class="emf-div-field">
<textarea id="element_5" name="element_5" cols="60" rows="10" class="validate[required]">
</textarea>
</div>
<div class="emf-clear"></div>
</li>
<li id="emf-li-recaptcha">
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</div>
</li>
<li id="emf-li-post-button" class="right">
<input value="Send email" type="submit" onmouseover="return true;" />
</li>
</ul><input name="element_counts" value="6" type="hidden" /> <input name="embed" value="forms" type="hidden" />
</form>
</div>
</div><br />
<div style="text-align:center">
<font face="Verdana" size="2" color="#000000">Powered by</font><span style="position: relative; padding-left: 3px; bottom: -5px;"><img src=
"http://www.emailmeform.com/builder/images/footer-logo.png" /></span><font face="Verdana" size="2" color="#000000">EMF</font> <a style="text-decoration:none;" href="http://www.emailmeform.com/"
target="_blank"><font face="Verdana" size="2" color="#000000">Web Forms Builder</font></a><br />
<a style="line-height:20px;font-size:70%;text-decoration:none;" href="http://www.emailmeform.com/report-abuse.html?http://www.emailmeform.com/builder/form/7zre918pa5a4Dv0kY" target=
"_blank"><font face="Verdana" size="2" color="#000000">Report Abuse</font></a>
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,5 :
function(field_value, value){
return field_value==value;
}
,6 :
function(field_value, value){
return field_value!=value;
}
,7 :
function(field_value, value){
return field_value==value;
}
,8 :
function(field_value, value){
return field_value>value;
}
,9 :
function(field_value, value){
return field_value<value;
}
,10 :
function(field_value, value){
var date_for_field_value=Date.parse(field_value);
var date_for_value=Date.parse(value);
if(date_for_field_value && date_for_value){
return date_for_field_value == date_for_value;
}
return false;
}
,11 :
function(field_value, value){
var date_for_field_value=Date.parse(field_value);
var date_for_value=Date.parse(value);
if(date_for_field_value && date_for_value){
return date_for_field_value < date_for_value;
}
return false;
}
,12 :
function(field_value, value){
var date_for_field_value=Date.parse(field_value);
var date_for_value=Date.parse(value);
if(date_for_field_value && date_for_value){
return date_for_field_value > date_for_value;
}
return false;
}
};
var emf_group_to_field_rules_map=[];
var emf_group_to_page_rules_for_confirmation_map=[];
//]]>
</script>
