Cumi Phone: REG

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      <td colspan="2"><span style="color: black; font-family: Verdana; font-size: x-small;"><b style="font-size: 20px;">PENDAFTARAN MEMBER BARU</b><br />
        <label style="font-size: 15px;">isi semua form dibawah ini untuk mendaftar sebagai member</label></span>
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      <td align="left" id="td_element_label_0"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>NAMA LENGKAP</b></span> <span style="color: red;"><small>*</small></span>
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      <td align="left" id="td_element_label_1"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>JENIS KELAMIN</b></span> <span style="color: red;"><small>*</small></span>
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      <td id="td_element_field_1"><div style="padding-bottom: 5px; width: 100%;">
<input class="validate[required]" id="element_1_0" name="element_1" type="radio" value="LAKI-LAKI" /><span style="color: black; font-family: Verdana; font-size: x-small;"> LAKI-LAKI </span>
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<input class="validate[required]" id="element_1_1" name="element_1" type="radio" value="PEREMPUAN" /><span style="color: black; font-family: Verdana; font-size: x-small;"> PEREMPUAN </span>
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      <td align="left" id="td_element_label_2"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>ALAMAT</b></span>
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      <td align="left" id="td_element_label_3"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Street Address</b></span>
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      <td align="left" id="td_element_label_4"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Address Line 2</b></span>
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      <td align="left" id="td_element_label_5"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>City</b></span>
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      <td align="left" id="td_element_label_6"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>State / Province / Region</b></span>
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      <td id="td_element_field_6"><input class="validate[optional]" id="element_6" name="element_6" size="30" type="text" value="" />
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      <td align="left" id="td_element_label_7"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Postal / Zip Code</b></span>
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      <td align="left" id="td_element_label_8"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Country</b></span>
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      <td align="left" id="td_element_label_9"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>NAMA SELLER</b></span> <span style="color: red;"><small>*</small></span>
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      <td id="td_element_field_9"><input class="validate[required]" id="element_9" name="element_9" size="30" type="text" value="" />
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<div style="color: black; padding-bottom: 8px;">
<small><span style="font-family: Verdana;">nama ini digunakan sebagai nama penjual nanti (contoh: MartinCell)</span></small>
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      <td align="left" id="td_element_label_10"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>NO.HANDPHONE</b></span> <span style="color: red;"><small>*</small></span>
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<div style="color: black; padding-bottom: 8px;">
<small><span style="font-family: Verdana;">no. hp yang digunakan untuk bertransaksi</span></small>
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      <td align="left" id="td_element_label_11"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>NAMA BANK</b></span> <span style="color: red;"><small>*</small></span>
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      <td id="td_element_field_11"><select class="validate[required]" id="element_11" name="element_11">
          <option selected="selected" value="">
            PILIH BANK
          </option>
          <option value="BNI">
            BNI
          </option>
          <option value="BRI">
            BRI
          </option>
          <option value="MANDIRI">
            MANDIRI
          </option>
          <option value="BCA">
            BCA
          </option>
          <option value="LIBERTY RESERVE (BANK ONLINE)">
            LIBERTY RESERVE (BANK ONLINE)
          </option>
          <option value="LAINNYA...">
            LAINNYA...
          </option>
        </select>
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<div style="color: black; padding-bottom: 8px;">
<small><span style="font-family: Verdana;">nama bank yang digunakan untuk deposit</span></small>
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      <td align="left" id="td_element_label_12"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>NO. REKENING</b></span> <span style="color: red;"><small>*</small></span>
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      <td align="left" id="td_element_label_13"><span style="color: black; font-family: Verdana; font-size: x-small;"><b>Email</b></span>
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      <td id="td_element_field_13"><input class="validate[optional,custom[email]]" id="element_13" name="element_13" size="30" type="text" value="" />
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