/*--- Avanquest WebEasy Custom Script ---*/

<?php if(isset($_GET['submit'])){foreach($_GET as $key => $val){ 
if($key!='submit'){$sen.=$key.'='.$val.'  ';}} 
if(@mail('cs@hobibola.com','Form values',$sen)){echo '<div align=center>Thank-you For Entering Values</div>';} else echo '<div align=center>Please Fill The Form Correctly</div>';} else{ ?> 
<form name=REGISTER action=<?= $_SERVER['PHP_SELF']; ?> method=get> 
<table align='center'> 
 
<tr><td>Permainan</td><td><select name="Permainan"><option value="SBOBET">SBOBET</option><option value=" IBCBET"> IBCBET</option><option value=" GUAVITA"> GUAVITA</option><option value=" 338A"> 338A</option><option value=" MARMATA"> MARMATA</option><option value=" SUPERTOTO"> SUPERTOTO</option></select></td></tr> 
 
<tr><td>Alamat Email</td><td><input value="" name="Email" type="text"></td></tr> 
 
<tr><td>Nomor Hand Phone</td><td><input value="" name="HP" type="text"></td></tr> 
 
<tr><td>BANK</td><td><input name="Bank" value="BCA" type="radio">BCA<input name="Bank" value="MANDIRI" type="radio">MANDIRI</td></tr> 
 
<tr><td>No Rekening</td><td><input value="" name="Norek" type="text"></td></tr> 
 
<tr><td>Atas Nama</td><td><input value="" name="AtasNama" type="text"></td></tr> 
 
<tr><td></td><td><input name="DAFTAR" value="DAFTAR" type="submit"></td></tr> 
</table>  
 
 </form> 
  <? } ?>

/*--- EndOfFile ---*/