misalkan nama filenya Pendaftaran.html
pada Gambar, lihat code yang bertuliskan img src=politeknik.gif, diganti dengan nama gambar sesuka anda, dimana gambar itu tersimpan satu folder dengan anda menyimpan kode HTML ini.
<html>
<head>
<body background="work.gif">
<title>PENDAFTARAN MASUK POLITEKNIK ACEH</title>
<form name="frm_pendaftaran" onSubmit="return verifikasi(this)">
<table bgcolor="black" width="75%" height="200" border="1" align="center" cellpadding="1">
<tr>
<td bgcolor="#56D9F5" height="200"> <table width="97%" height="121" border="0" align="center" cellpadding="3">
<tr>
<td width="21%" height="117"><div align="center"><img src="tut.GIF" width="100" height="100"></div></td>
<td width="54%"><div align="center"><font size="5" face="Geneva, Arial, Helvetica, sans-serif"><strong>FORMULIR
PENDAFTARAN<br>
UJIAN MASUK POLITEKNIK ACEH <br>
2011/2012</strong><br>
</font></div></td>
<td width="25%"><div align="center"><img src="Politeknikaceh.GIF" width="207" height="91"></div></td>
</tr>
</table></td>
<table bgcolor="black" width="75%" height="50" border="1" align="center" cellpadding="1">
<td bgcolor="black" height="20"> <table width="97%" height="10" border="0" align="center" cellpadding="3">
<tr><marquee direction="Left"><font color="red">Selamat Datang Para Calon Mahasiswa Baru Politeknik Aceh, Desa Pango Raya, JL.Politeknik Aceh - Tepi Kali, Banda Aceh. Telp.(0651)31855</marquee></font></tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="27"><table width="789" border="0" align="center" cellpadding="1">
<tr>
<td width="25" height="28"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">1</font></td>
<td width="202"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nomor
Ujian</font></td>
<td width="548"><input name="txt_no_ujian" type="text" id="txt_no_ujian" size="20"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="27"><table width="789" border="0" align="center" cellpadding="1">
<tr>
<td width="25" height="28"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">2</font></td>
<td width="201"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nama
Peserta</font></td>
<td width="549"><input name="txt_nama_peserta" type="text" id="txt_nama_peserta" size="30"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="27"><table width="789" border="0" align="center" cellpadding="1">
<tr>
<td width="25" rowspan="2"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">3</font></td>
<td width="200" rowspan="2"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Jenis
Kelamin</font></td>
<td width="171"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
<input type="radio" name="rd_jk" value="Laki-laki">
Laki-laki</font></td>
<td width="119"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">4.
Status</font></td>
<td width="252"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
<input type="radio" name="rd_status" value="Menikah">
Menikah</font></td>
</tr>
<tr>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
<input type="radio" name="rd_jk" value="Perempuan">
Perempuan</font></td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif"> </font></td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">
<input type="radio" name="rd_status" value="Belum Menikah">
Belum Menikah</font></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">5</font></td>
<td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Tempat
Lahir</font></td>
<td width="545"><input name="txt_tmpt_lhr" type="text" id="txt_tmpt_lhr" size="30"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">6</font></td>
<td width="195"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Tanggal
Lahir</font></td>
<td width="546">
<select name="slc_tgl" id="slc_tgl">
<option selected>-</option><option>1</option><option>2</option><option>3</option><option>4</option><option>5</option><option>6</option><option>7</option><option>8</option><option>9</option><option>10</option><option>11</option><option>12</option><option>13</option><option>14</option><option>15</option><option>16</option><option>17</option><option>18</option><option>19</option><option>20</option><option>21</option><option>22</option><option>23</option><option>24</option><option>25</option><option>26</option><option>27</option><option>28</option><option>29</option><option>30</option><option>31</option>
</select>
/
<select name="slc_bln" id="slc_bln">
<option selected>-</option><option>1</option><option>2</option><option>3</option><option>4</option><option>5</option><option>6</option><option>7</option><option>8</option><option>9</option><option>10</option><option>11</option><option>12</option> </select>
<select name="slc_thn" id="slc_thn">
<option selected>-</option><option>1970</option><option>1971</option><option>1972</option><option>1973</option><option>1974</option><option>1975</option><option>1976</option><option>1977</option><option>1978</option><option>1979</option><option>1980</option><option>1981</option><option>1982</option><option>1983</option><option>1984</option><option>1985</option><option>1986</option><option>1987</option><option>1988</option><option>1989</option><option>1990</option><option>1991</option><option>1992</option><option>1993</option><option>1994</option><option>1995</option><option>1996</option><option>1997</option><option>1998</option><option>1999</option><option>2000</option><option>2001</option><option>2002</option><option>2003</option><option>2004</option><option>2005</option><option>2006</option><option>2007</option><option>2008</option><option>2009</option><option>2010</option><option>2011</option><option>2012</option><option>2013</option><option>2014</option><option>2015</option><option>2016</option><option>2017</option><option>2018</option><option>2019</option>
</select></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="240"><table width="789" border="0" align="center" cellpadding="1">
<tr>
<td width="26"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">7</font></td>
<td width="199"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Alamat
Surat</font></td>
<td width="135"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Jalan</font></td>
<td width="411"><input name="txt_jalan" type="text" id="txt_jalan" size="50"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Desa</font></td>
<td><input name="txt_desa" type="text" id="txt_desa" size="50"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Kecamatan</font></td>
<td><input name="txt_kecamatan" type="text" id="txt_kecamatan" size="50"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Kabupaten</font></td>
<td><input name="txt_kabupaten" type="text" id="txt_kabupaten" size="50"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Provinsi</font></td>
<td><input name="txt_provinsi" type="text" id="txt_provinsi" size="50"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Kode
Pos</font></td>
<td><input name="txt_kodepos" type="text" id="txt_kodepos" size="30"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Telp</font></td>
<td><input name="txt_mhs_telp" type="text" id="txt_mhs_telp" size="30"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">HP</font></td>
<td><input name="txt_hp" type="text" id="txt_hp" size="30"></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Email</font></td>
<td><input name="txt_email" type="text" id="txt_email" size="50"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">8</font></td>
<td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Agama</font></td>
<td width="545"><select name="slc_agama" id="slc_agama">
<option selected>Islam</option>
<option>Kristen Protestan</option>
<option>Kristen Katholik</option>
<option>Budha</option>
<option>Hindu</option>
</select></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="17"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">9</font></td>
<td width="197"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Asal
Sekolah</font></td>
<td width="544"><input name="txt_sekolah" type="text" id="txt_sekolah" size="30"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="18"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">10</font></td>
<td width="197"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Asal
Jurusan</font></td>
<td width="544"><input name="txt_jurusan" type="text" id="txt_jurusan" size="30"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="16"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">11</font></td>
<td width="204"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">No.
Ijazah</font></td>
<td width="218"><input name="txt_ijazah" type="text" id="txt_ijazah" size="30"></td>
<td width="143"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Tahun
Lulus</font></td>
<td width="166"><input name="txt_tahun_lulus" type="text" id="txt_tahun_lulus" size="10"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="33"><table width="790" border="0" align="center" cellpadding="3">
<tr>
<td width="20"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">12</font></td>
<td width="199"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nilai
Ijazah/Jumlah Pelajaran</font></td>
<td width="179"><input name="txt_nilai_ijazah" type="text" id="txt_nilai_ijazah" size="10">
/
<input name="txt_jumpel_ijazah" type="text" id="txt_jumpel_ijazah" size="5"></td>
<td width="189"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nilai
UAN/Jumlah Pelajaran</font></td>
<td width="161"><input name="txt_uan" type="text" id="txt_uan" size="10">
/
<input name="txt_nilai_uan" type="text" id="txt_nilai_uan" size="5"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">13</font></td>
<td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nama
Ayah</font></td>
<td width="545"><input name="txt_nama_ayah" type="text" id="txt_nama_ayah" size="30"></td>
</tr>
<tr>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pekerjaan</font></td>
<td><input name="txt_pkrjaan_ayah" type="text" id="txt_pkrjaan_ayah" size="30"></td>
</tr>
</table></td>
</tr>
<tr>
<td bgcolor="gray" height="37"><table width="789" border="0" align="center" cellpadding="3">
<tr>
<td width="22"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">14</font></td>
<td width="196"><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Nama
Ibu</font></td>
<td width="545"><input name="txt_nama_ibu" type="text" id="txt_nama_ibu" size="30"></td>
</tr>
<tr>
<td> </td>
<td><font size="2" face="Verdana, Arial, Helvetica, sans-serif">Pekerjaan</
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