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					<b>Topic</b>: &nbsp;<a class="menufx" href="/default.asp?topic=membership&speak=id">membership</a><span style="color: #aaaaaa"> &#151; </span><a class="menufx" href="/default.asp?topic=membership,request&speak=id">request</a></div>
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					<b>Speak</b>: id</div>
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				<ul class="sidemenu"><li><a href="http://www.jci.cc/" target="_blank"><span>International</span></a></li><li><a href="/" target="_blank"><span>Indonesia</span></a></li></ul><ul class="sidemenu"><li><a href="/president/" target="_blank"><span>National President</span></a></li><li><a href="/senate/" target="_blank"><span>Indonesia Senate</span></a></li></ul><ul class="sidemenu"><li><a href="/lom/areksuroboyo/" target="_blank"><span>Arek Suroboyo</span></a></li><li><a href="/lom/bali/" target="_blank"><span>Bali</span></a></li><li><a href="/lom/bogorraya/" target="_blank"><span>Bogor Raya</span></a></li><li><a href="/lom/jakarta/" target="_blank"><span>Jakarta</span></a></li><li><a href="/lom/medan/" target="_blank"><span>Medan</span></a></li><li><a href="/lom/piasemarang/" target="_blank"><span>PIA Semarang</span></a></li><li><a href="/lom/yogyakarta/" target="_blank"><span>Yogyakarta</span></a></li><li><a href="/lom/batavia/" target="_blank"><span>Batavia</span></a></li><li><a href="/lom/palembang/" target="_blank"><span>Palembang</span></a></li><li><a href="/lom/ubud/" target="_blank"><span>Ubud</span></a></li></ul>
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			<tr>
				<td valign="top" nowrap align="middle" bgcolor="#eeeeee"><b>&nbsp;JCI 
				Indonesia - Membership - Request</b></td>
			</tr>
			<tr>
				<td nowrap>
				<table cellspacing="0" cellpadding="2" width="100%" border="0">
					<tr>
						<td nowrap align="right">Nama</td>
						<td>: </td>
						<td width="100%">
						<input style="WIDTH: 300px" size="30" name="Name"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="right">Kelamin</td>
						<td>:</td>
						<td><select size="1" name="gender">
						<option value="---">----</option>
						<option value="pria">pria</option>
						<option value="wanita">wanita</option>
						</select><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="right">Status</td>
						<td>:</td>
						<td><select size="1" name="status">
						<option value="---">----</option>
						<option value="kawin">kawin</option>
						<option value="lajang">lajang</option>
						</select><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="center" colspan="3" bgcolor="#ffffee">&nbsp;</td>
					</tr>
					<tr>
						<td nowrap align="right">Email</td>
						<td>:</td>
						<td><input style="WIDTH: 300px" size="30" name="Email"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="right">Phone</td>
						<td>:</td>
						<td><input style="WIDTH: 150px" size="15" name="Phone"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="center" colspan="3" bgcolor="#ffffee">&nbsp;</td>
					</tr>
					<tr>
						<td nowrap align="right">Jabatan</td>
						<td>:</td>
						<td>
						<input style="WIDTH: 300px" size="30" name="Position"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="right">Organisasi</td>
						<td>:</td>
						<td>
						<input style="WIDTH: 300px" size="30" name="Organization"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td align="middle" bgcolor="#ffffee" colspan="3">&nbsp;</td>
					</tr>
					<tr>
						<td nowrap align="right">Jalan1</td>
						<td>:</td>
						<td>
						<input style="WIDTH: 300px" size="30" name="Street1"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="right">Jalan2</td>
						<td>:</td>
						<td>
						<input style="WIDTH: 300px" size="30" name="Street2"></td>
					</tr>
					<tr>
						<td nowrap align="right">Kota</td>
						<td>:</td>
						<td><input style="WIDTH: 300px" size="30" name="City"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="right">Propinsi</td>
						<td>:</td>
						<td>
						<input style="WIDTH: 300px" size="30" name="Province"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td nowrap align="right">Kode Pos</td>
						<td>:</td>
						<td>
						<input style="WIDTH: 50px" size="5" name="Postalcode" maxlength="5"><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td align="middle" bgcolor="#ffffee" colspan="3">&nbsp;</td>
					</tr>
					<tr>
						<td align="right" nowrap>Kelahiran</td>
						<td>: </td>
						<td><select size="1" name="Date">
						<option value="---">----</option>
						<option value="1">1</option>
						<option value="2">2</option>
						<option value="3">3</option>
						<option value="4">4</option>
						<option value="5">5</option>
						<option value="6">6</option>
						<option value="7">7</option>
						<option value="8">8</option>
						<option value="9">9</option>
						<option value="10">10</option>
						<option value="11">11</option>
						<option value="12">12</option>
						<option value="13">13</option>
						<option value="14">14</option>
						<option value="15">15</option>
						<option value="16">16</option>
						<option value="17">17</option>
						<option value="18">18</option>
						<option value="19">19</option>
						<option value="20">20</option>
						<option value="21">21</option>
						<option value="22">22</option>
						<option value="23">23</option>
						<option value="24">24</option>
						<option value="25">25</option>
						<option value="26">26</option>
						<option value="27">27</option>
						<option value="28">28</option>
						<option value="29">29</option>
						<option value="30">30</option>
						<option value="31">31</option>
						</select><select size="1" name="Month">
						<option value="---">----</option>
						<option value="1">1</option>
						<option value="2">2</option>
						<option value="3">3</option>
						<option value="4">4</option>
						<option value="5">5</option>
						<option value="6">6</option>
						<option value="7">7</option>
						<option value="8">8</option>
						<option value="9">9</option>
						<option value="10">10</option>
						<option value="11">11</option>
						<option value="12">12</option>
						</select><select size="1" name="Year">
						<option value="---">----</option>
						<option value="1965">1965</option>
						<option value="1966">1966</option>
						<option value="1967">1967</option>
						<option value="1968">1968</option>
						<option value="1969">1969</option>
						<option value="1970">1970</option>
						<option value="1971">1971</option>
						<option value="1972">1972</option>
						<option value="1973">1973</option>
						<option value="1974">1974</option>
						<option value="1975">1975</option>
						<option value="1976">1976</option>
						<option value="1977">1977</option>
						<option value="1978">1978</option>
						<option value="1979">1979</option>
						<option value="1980">1980</option>
						<option value="1981">1981</option>
						<option value="1982">1982</option>
						<option value="1983">1983</option>
						<option value="1984">1984</option>
						<option value="1985">1985</option>
						<option value="1986">1986</option>
						<option value="1987">1987</option>
						</select><font color="#FF0000">*</font></td>
					</tr>
					<tr>
						<td align="middle" bgcolor="#ffffee" colspan="3">&nbsp;</td>
					</tr>
					<tr>
						<td nowrap align="right" valign="top">Alasan<br>
						bergabung</td>
						<td valign="top">:</td>
						<td valign="top">
						<table border="0" cellspacing="0" cellpadding="0">
							<tr>
								<td valign="top">
								<textarea style="WIDTH: 300px; height: 60px" rows="4" cols="20" name="Reason"></textarea></td>
								<td valign="top"><font color="#FF0000">*</font></td>
							</tr>
						</table>
						</td>
					</tr>
				</table>
				<table cellspacing="1" cellpadding="1" width="200" border="1">
				</table>
				<table cellspacing="0" cellpadding="0" width="100%" border="0">
					<tr>
						<td nowrap colspan="2"><hr noshade size="1"></td>
					</tr>
					<tr>
						<td nowrap width="100%"><font color="#FF0000">*</font> harus 
						diisi</td>
						<td nowrap>
						<table cellspacing="0" cellpadding="4" align="right" border="0">
							<tr>
								<td nowrap>
								<input class="button" style="WIDTH: 80px" type="submit" value="Submit" name="btnSubmit">
								<input class="button" style="WIDTH: 80px" type="reset" value="Reset" name="btnReset"></td>
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				<p align="center" style="margin: 0;"><table width="140" border="0" cellspacing="2" cellpadding="0"><tr><td width="50%" bgcolor="#eeeedd" align="center" style="border: 1px solid #bbbbbb"><a href="default.asp?topic=membership,request&speak=en">English</a></td><td width="50%" bgcolor="#ddeeee" align="center" style="border: 1px solid #bbbbbb"><a href="default.asp?topic=membership,request&speak=id"><b>Indonesia</b></a></td></tr></table></p>
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						<td bgcolor="#dd2222" align="center"><font color="#eeeeee"><b>Become a JCI member?</b></font></td>
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					<tr>
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						Click
						<a href="default.asp?topic=membership,request&speak=id">
						here</a></td>
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<h3>News/Events</h3>
<ul class="sidemenu">
	<li><a href="/default.asp?topic=directory,bod+2010&amp;speak=id">1. National BOD 2010<br />
	</a></li>
	<li><a href="/default.asp?topic=directory,national+work+2010&amp;speak=id">2. National Work 2010</a></li>
	<li></li>
	<li id="right"><a href="/default.asp?topic=news&amp;speak=id"><span style="font-weight: bold">Archives...</span></a></li>
</ul>
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<div style="border: 1px solid #d0d0d0; margin: 5px 0pt; background-color: #f8f8f0">
<h3>Wise Words</h3>
<p align="left">
If a man has talent and does not use it, he 
has failed;
</p>
<p align="left">
If he has talent and uses only half of it, he 
has partialty failed;
</p>
<p align="left">
If he has talent and learns to use the whole 
of it, he has gloriously succeeded, and knows a satisfaction 
and triumph few will ever know
</p>
<p align="right">
<b>Thomas Wolfe</b>
</p>
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