<?php 
	error_reporting(0);
	include "../../app.siakad-akperpasarrebo.ac.id/jangan_dibuka/perhatian.php";
  
	$mn = $_GET['mn'];
	$em = $_GET['em'];
	$query= mysqli_query($conn,"select * from calon_mahasiswa where nama_lengkap LIKE ('%$mn%') AND email LIKE ('%$em%')");
	$cek_data = mysqli_num_rows($query);
// 	echo"cek data : $cek_data";
	if($cek_data>0){
	   // echo"cek data1 : $cek_data";
	    echo"Silahkan ulangi lagi isikan Nama Lengkap dan email.";
	}else{
	   // echo"cek data3 : $cek_data";
	    ?>
	    <div class="row form-group">
	        <div class="col-md-12">
	            <label for="fname">Kategori Pemberi Rekomendasi</label>
	            <select name="kategori_rekomendasi" class="form-control">
	                <option value="#" selected >Pilih Kategori</option>
	                <option value="1" >1. Mahasiswa</option>
	                <option value="2" >2. Karyawan Akper</option>
	                <option value="3" >3. Alumni</option>
	                <option value="4" >4. Lainnya</option>
	            </select>
	        </div>
	        <div class="col-md-12">
	            <label for="fname">Nama Pemberi Rekomendasi</label>
	            <input type="text" id="pemberi_rekomendasi" class="form-control" name="pemberi_rekomendasi" placeholder="Di isi jika mendapatkan rekomendasi">
	        </div>
	   </div>
	   <div class="row form-group">
	        <div class="col-md-6">
	            <label for="fname">No. Induk Siswa Nasional</label>
	            <input type="text" id="fname" class="form-control" name="nisn" placeholder="NISN" required>
	       </div>
	       <div class="col-md-6">
	            <label for="fname">No. Induk Penduduk</label>
	            <input type="text" id="fname" class="form-control" name="nik" placeholder="NIK" required>
	       </div>
	   </div>
	   <div class="row form-group">
	        <div class="col-md-6">
	            <label for="fname">Tempat Lahir</label>
	            <input type="text" id="fname" class="form-control" name="tempat_lahir" placeholder="Tempat Lahir" required>
	       </div>
	       <div class="col-md-6">
	            <label for="fname">Tanggal Lahir</label>
	            <input type="date" id="fname" class="form-control" name="tanggal_lahir" placeholder="Tanggal Lahir" required>
	       </div>
	   </div>
	   <div class="row form-group">
	        <div class="col-md-3">
	            <label for="fname">Agama</label>
	            <select name="agama" class="form-control">
	                <option value="#" selected >Pilih Agama</option>
	                <option value="1" >1. Islam</option>
	                <option value="2" >2. Keristen Katolik</option>
	                <option value="3" >3. Keristen Protestan</option>
	                <option value="4" >4. Budha</option>
	                <option value="5" >5. Hindu</option>
	                <option value="6" >6. Konghucu</option>
	            </select>
	        </div>
	        <div class="col-md-3">
	            <label for="email">Jenis Kelamin</label>
	            <select name="jenis_kelamin" class="form-control" required>
	                <option value="0" selected >Jenis Kelamin</option>
	                <option value="1" >1. Pria</option>
	                <option value="2" >2. Wanita</option>
	            </select>
	        </div>
	        <div class="col-md-3">
	            <label for="subject">Tinggi Badan</label>
	            <input type="text" class="form-control" name="tinggi_badan" placeholder="Tinggi Badan"  value=""  required/>
	        </div>
	        <div class="col-md-3">
	            <label for="subject">Berat Badan</label>
	            <input type="text" class="form-control" name="berat_badan" placeholder="Berat Badan"  value=""  required/>
	        </div>
	   </div>
	   <div class="row form-group">
	        <div class="col-md-12">
	            <label for="email">Riwayat Penyakit</label>
	            <input type="text" class="form-control" name="riwayat_penyakit" placeholder="Penyakit Parah Yang Pernah Dialami"  value=""  required/>
	        </div>
	   </div>
	   <div class="row form-group">
	        <div class="col-md-12">
	            <label for="email">Ibu Kandung</label>
	            <input type="text" class="form-control" name="nama_ibu" placeholder="Nama Ibu Kandung"  value=""  required/>
	        </div>
	    </div>
	    <div class="row form-group">
	        <div class="col-md-8">
	            <label for="message">Alamat</label>
	            <textarea name="alamat" id="message" cols="30" rows="10" class="form-control" placeholder="Alamat Tinggal" required></textarea>
	        </div>
	        <div class="col-md-2">
	            <label for="message">RT</label>
	            <input type="text" class="form-control" name="rt" placeholder="RT"  value=""  required/>
	        </div>
	        <div class="col-md-2">
	            <label for="message">RW</label>
	            <input type="text" class="form-control" name="rw" placeholder="RW"  value=""  required/>
	        </div>
	    </div>
	    <div class="row form-group">
	        <div class="col-md-3">
	            <label for="message">Provinsi</label>
	            <select name="id_prov" class="form-control" onchange="pilihKota(this.value);">
	                <option value="0" selected>Select Provinsi</option>
	                <?Php   
	                    $prov = mysql_query("select id_prov,nama_prov from m_provinsi order by nama_prov ASC");
	                    while($t = mysql_fetch_array($prov)){
	                        echo"<option value='$t[id_prov]'>$t[nama_prov]</option>";
	                    }
	                ?>
	            </select>
	        </div>
	        <div class="col-md-3">
	            <label for="message">Kabupaten/Kota</label>
	            <select name="kota" id="txtHintKota" class="form-control" onchange="pilihKecamatan(this.value);">
	                <option value="0" selected>Select Kabupaten/Kota</option>
	                <?Php   
	                echo"<option value='#'>Select Kabupaten/Kota</option>";
	                ?>
	            </select>
	        </div>
	        <div class="col-md-3">
	            <label for="shipping_address_1" >Kecamatan </label>
	            <select name="kecamatan" id="txtHint" class="form-control" onchange="pilihKelurahan(this.value);">
	            <?Php   
	            echo"<option value='#'>Select Kecamatan</option>";
	            ?>
	            </select>
	        </div>
	        <div class="col-md-3">
	            <label for="shipping_address_1" >Kelurahan </label>
	            <select name="kelurahan" id="txtHintt" class="form-control" >
	            <?Php   
	            echo"<option value='#'>Select Kelurahan</option>";
	            ?>
	            </select>
	        </div>
	    </div>
	    <div class="row form-group">
	        <div class="col-md-6">
	            <label for="email">Telepon Orangtua</label>
	            <input type="text" class="form-control" name="telepon1" placeholder="Telepon 1"  value=""  required/>
	        </div>
	        <div class="col-md-6">
	            <label for="email">Telepon Pendaftar</label>
	            <input type="text" class="form-control" name="telepon2" placeholder="Telepon2"  value=""  required/>
	        </div>
	    </div>
	    <div class="row form-group">
	        <div class="col-md-12">
	            <label for="email">Asal Sekolah</label>
	            <input type="text" class="form-control" name="asal_sekolah" placeholder="asal_sekolah"  value=""  required/>
	        </div>
	    </div>
	    <div class="row form-group">
	        <div class="col-md-12">
	            <label for="email">Pekerjaan Orang Tua</label>
	            <input type="text" class="form-control" name="pekerjaan_ortu" placeholder="pekerjaan_ortu"  value=""  required/>
	        </div>
	    </div>
	    <div class="row form-group">
	        <div class="col-md-12">
	            <label for="email">Pendapatan Orang Tua</label>
	            <input type="number" class="form-control" name="pendapatan_ortu" placeholder="pendapatan_ortu"  value=""  required/>
	        </div>
	    </div>
	    <div class="row form-group">
	        <div class="col-md-12">
	            <img src='../captcha.php'></br>
	            (Masukkan 6 kode diatas)<br /><input type=text class="form-control"  name='kode' size=6 maxlength=6>
	        </div>
	    </div>
	    <div class="form-group">
	        <input type="submit" value="Kirim" class="btn btn-addon btn-primary waves-effect" >
	        <a href="https://bit.ly/FORMPMBAPR" class="btn btn-info" target='_blank' >Form Pernyataan Bebas Narkoba</a>
	    </div>
	    <?Php
	}
?>