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index.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Surat Keterangan Tempat Tinggal</title>
<style>
body {
font-family: sans-serif;
text-align: center;
}
table {
border-collapse: collapse;
width: 100%;
margin: 0 auto;
}
th, td {
text-align: left;
padding: 8px;
border: 1px solid black;
}
th {
background-color: #f2f2f2;
}
.form-group {
margin-bottom: 15px;
}
.form-label {
display: block;
margin-bottom: 5px;
}
.header-table {
width: 100%;
border-collapse: collapse;
margin-bottom: 20px;
}
.header-table td {
border: none;
padding: 0;
}
.header-table img {
width: 100px;
height: 100px;
margin-right: 20px;
}
.header-table h1, h2, h3, p {
margin: 0;
}
</style>
</head>
<body>
<table class="header-table">
<tr>
<td>
<img src="gambar_logo.png" alt="Logo Pemerintah">
</td>
<td style="text-align: center;">
<h1>PEMERINTAH KABUPATEN BARITO KUALA</h1>
<h2>KECAMATAN MANDASTANA</h2>
<h3>KEPALA DESA TABING RIMBAH</h3>
<p>Alamat: ....</p>
</td>
</tr>
</table>
<hr style="border-top: 3px solid black;">
<h2>SURAT KETERANGAN TEMPAT TINGGAL</h2>
<p>Nomor: ..........................</p>
<form>
<table>
<tr>
<th>Nama</th>
<td><input type="text" name="nama" required></td>
</tr>
<tr>
<th>Tempat/Tgl. Lahir</th>
<td><input type="date" name="tanggal_lahir" required></td>
</tr>
<tr>
<th>Pekerjaan</th>
<td><input type="text" name="pekerjaan" required></td>
</tr>
<tr>
<th>Agama</th>
<td><input type="text" name="agama" required></td>
</tr>
<tr>
<th>Jenis Kelamin</th>
<td>
<label for="laki-laki">Laki-laki</label>
<input type="radio" name="jenis_kelamin" id="laki-laki" value="Laki-laki" required>
<label for="perempuan">Perempuan</label>
<input type="radio" name="jenis_kelamin" id="perempuan" value="Perempuan" required>
</td>
</tr>
<tr>
<th>Alamat</th>
<td><textarea name="alamat" required></textarea></td>
</tr>
</table>
<table>
<tr>
<td style="text-align: right;">Tabing Rimbah, <input type="date" name="tanggal" required></td>
</tr>
<tr>
<td colspan="2" style="text-align: right; margin-top: 10px;">
<p>Kepala Desa Tabing Rimbah</p>
<p><input type="text" name="nama_kepala_desa" required></p>
</td>
</tr>
</table>
</form>
</body>
</html>