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<form data-instance="1" class="CF66508aabb67c6 caldera_forms_form cfajax-trigger _tisBound" method="POST" enctype="multipart/form-data" id="CF66508aabb67c6_1" data-form-id="CF66508aabb67c6" aria-label="dewi9" data-target="#caldera_notices_1"
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    <label>Phone</label><input type="text" name="phone" value="" autocomplete="off">
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        <label id="fld_6684781Label" for="fld_6684781_1" class="control-label">User ID yang Di Inginkan <span aria-hidden="true" role="presentation" class="field_required" style="color:#ee0000;">*</span></label>
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            <option value="" disabled="" selected="">Pilih Jenis Pembayaran</option>
            <option value="BCA Bank Central Asia" data-calc-value="BCA Bank Central Asia"> BCA Bank Central Asia </option>
            <option value="BRI Bank Republik Indonesia" data-calc-value="BRI Bank Republik Indonesia"> BRI Bank Republik Indonesia </option>
            <option value="BNI Bank Nasional Indonesia" data-calc-value="BNI Bank Nasional Indonesia"> BNI Bank Nasional Indonesia </option>
            <option value="MANDIRI Bank Mandiri" data-calc-value="MANDIRI Bank Mandiri"> MANDIRI Bank Mandiri </option>
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            <option value="LINK AJA" data-calc-value="LINK AJA"> LINK AJA </option>
            <option value="PULSA TELKOMSEL" data-calc-value="PULSA TELKOMSEL"> PULSA TELKOMSEL </option>
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            aria-describedby="fld_1302473Caption"> <span id="fld_1302473Caption" class="help-block">Masukkan Nomor Rekening Bank jika menggunakan Bank, Atau Masukkan no telp jika menggunakan Pulsa</span>
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      <input type="hidden" data-field="fld_2944016" class=" form-control" id="fld_2944016_1" name="fld_2944016" value="https://agindewi.click/" data-type="hidden">
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</form>

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Phone
Nama Lengkap *

User ID yang Di Inginkan *

Akun Bank / Pulsa *
Pilih Jenis Pembayaran BCA Bank Central Asia BRI Bank Republik Indonesia BNI
Bank Nasional Indonesia MANDIRI Bank Mandiri DANA GOPAY OVO LINK AJA PULSA
TELKOMSEL PULSA XL/AXIS
Nomor Rekening / Pulsa *
Masukkan Nomor Rekening Bank jika menggunakan Bank, Atau Masukkan no telp jika
menggunakan Pulsa


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