<link href="http://www.emailmeform.com/builder/styles/dynamic.php?t=post" rel="stylesheet" type="text/css"></link>
<script src="http://www.emailmeform.com/builder/js/dynamic.php?t=post&t2=0" type="text/javascript">
</script>
<form
action="http://www.emailmeform.com/builder/form/ktdjv6en4Wba8"
enctype="multipart/form-data" id="emf-form" method="post"
name="emf-form">
<table bgcolor="transparent" border="0" cellpadding="2" cellspacing="0" style="text-align: left;"><tbody>
<tr> <td colspan="2">
<span
style="color: black; font-family: Verdana; font-size:
x-small;"><b style="font-size: 20px;">Kirim Testtimony Di
Sini</b>
</span></td> </tr>
<tr valign="top"> <td align="">
<span
style="color: black; font-family: Verdana; font-size:
x-small;"><b>NAMA</b></span> <span style="color:
red;"><small>*</small></span></td>
</tr>
<tr> <td>
<input class="validate[required,custom[email]]" id="element_0" name="element_0" size="30" type="text" value="" />
<div style="color: black; padding-bottom: 8px;">
</div>
</td> </tr>
<tr valign="top"> <td align="">
<span
style="color: black; font-family: Verdana; font-size:
x-small;"><b>KODE AKTIVASI</b></span> <span
style="color:
red;"><small>*</small></span></td>
</tr>
<tr> <td>
<input class="validate[required]" id="element_1" name="element_1" size="30" type="text" value="" />
<div style="color: black; padding-bottom: 8px;">
</div>
</td> </tr>
<tr valign="top"> <td align="">
<span
style="color: black; font-family: Verdana; font-size:
x-small;"><b>Subject</b></span> <span
style="color:
red;"><small>*</small></span></td>
</tr>
<tr> <td>
<input class="validate[required]" id="element_2" name="element_2" size="30" type="text" value="" />
<div style="color: black; padding-bottom: 8px;">
</div>
</td> </tr>
<tr valign="top"> <td align="">
<span
style="color: black; font-family: Verdana; font-size:
x-small;"><b>Message</b></span> <span
style="color:
red;"><small>*</small></span></td>
</tr>
<tr> <td>
<textarea
class="validate[required]" cols="60" id="element_3" name="element_3"
rows="10"><br /> </textarea>
<div style="color: black; padding-bottom: 8px;">
</div>
</td> </tr>
<tr> <td align="right" colspan="2">
<input
name="element_counts" type="hidden" value="4" /> <input
name="embed" type="hidden" value="forms" /><input type="submit"
value="Send email" /><input type="reset" value="Clear"
/></td> </tr>
</tbody></table>
</form>
<script type="text/javascript">
//<![CDATA[
$('body').append('
<div>
<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"><font face="Verdana"
size="2" color="#000000">HTML Form
Builder<\/font><\/font><\/a><\/div><font
face="Verdana" size="2" color="#000000"><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/ktdjv6en4Wba8"
target="_blank">Report Abuse<\/a><\/font>')
//]]>
</script><script type="text/javascript">
//<![CDATA[
$(function(){
$("#emf-form").validationEngine({
validationEventTriggers:"blur",
scroll:false
});
$('.datepicker').datepicker({
showOn: 'button',
buttonImage: base_url+'images/calendar.png',
buttonImageOnly: true,
onSelect: function(dateText, inst) {
var selectedDate = new Date(dateText);
$('#'+inst.id+'year').val(selectedDate.getFullYear());
$('#'+inst.id+'year-mm').val(((selectedDate.getMonth()+1)>9)?(selectedDate.getMonth()+1):('0'+(selectedDate.getMonth()+1)));
$('#'+inst.id+'year-dd').val(selectedDate.getDate()>9?selectedDate.getDate():'0'+selectedDate.getDate());
$('.'+inst.id+'yearformError').remove();
$('.'+inst.id+'year-mmformError').remove();
$('.'+inst.id+'year-ddformError').remove();
},
changeMonth: true,
changeYear: true
});
if(document.getElementById('captcha_image')!=null){
get_valid_captcha();
}
if(document.getElementById('captcha_image')!=null){
var isSafari = (/Safari/.test(navigator.userAgent));
var firstTimeSession = 0;
function process_captcha(){
$('a#captcha_code_refresh').trigger('click');
get_valid_captcha();
}
function safari_submit_session_form() {
if (firstTimeSession == 0) {
firstTimeSession = 1;
$("#safari_sessionform").submit();
setTimeout('process_captcha()',2000);
}
}
if(isSafari){
$("body").append('<iframe id="safari_sessionframe"
name="safari_sessionframe" onload="safari_submit_session_form();"
src="http://www.emailmeform.com/get_safari_cookies.php"
style="display:none;"><\/iframe><form
id="safari_sessionform" enctype="application/x-www-form-urlencoded"
action="http://www.emailmeform.com/get_safari_cookies.php"
target="safari_sessionframe" action="post">
<\/form>');
}
}
});
//]]>
</script>
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