<?php
include("dist/config/koneksi.php");
include("home_top.php");
$tanggal = date('Y-m-d');
?>

<div class="container mt-5">
  <h1 class="text-center mb-4">Form Permohonan Pindah Keluar</h1>
  <form class="form-horizontal" action="keteranganpindahkeluar_insert.php" method="POST" enctype="multipart/form-data">
  <div class="mb-3">
      <label for="nama" class="form-label">Id Penduduk</label>
      <input type="number" class="form-control" id="id_penduduk" name="id_penduduk" placeholder="Masukkan Id Penduduk">
    </div>
    <div class="mb-3">
      <label for="nama" class="form-label">Desa Baru</label>
      <input type="text" class="form-control" id="desa_baru" name="desa_baru" placeholder="Masukkan Nama Desa Baru">
    </div>
    <div class="mb-3">
      <label for="alamat" class="form-label">Alamat Baru</label>
      <textarea class="form-control" id="jalan_baru" name="jalan_baru" rows="3" placeholder="Masukkan Alamat Baru"></textarea>
    </div>
    <div class="mb-3">
      <label for="nama" class="form-label">RT Baru</label>
      <input type="text" class="form-control" id="rt_baru" name="rt_baru" placeholder="Masukkan Nama RT Baru">
    </div>
    <div class="mb-3">
      <label for="nama" class="form-label">RW Baru</label>
      <input type="text" class="form-control" id="rw_baru" name="rw_baru" placeholder="Masukkan Nama RW Baru">
    </div>
    <div class="mb-3">
      <label for="nama" class="form-label">Kecamatan Baru</label>
      <input type="text" class="form-control" id="kecamatan_baru" name="kecamatan_baru" placeholder="Masukkan Nama Kecamatan Baru">
    </div>
    <div class="mb-3">
      <label for="nama" class="form-label">Kabupaten Baru</label>
      <input type="text" class="form-control" id="kabupaten_baru" name="kabupaten_baru" placeholder="Masukkan Nama Kabupaten Baru">
    </div>
    <div class="mb-3">
      <label for="nama" class="form-label">Provinsi Baru</label>
      <input type="text" class="form-control" id="provinsi_baru" name="provinsi_baru" placeholder="Masukkan Nama Provinsi Baru">
    </div>
    <div class="mb-3">
      <label for="alamat" class="form-label">Keterangan Pindah</label>
      <textarea class="form-control" id="keterangan_pindah" name="keterangan_pindah" rows="3" placeholder="Masukkan Keterangan Pindah"></textarea>
    </div>
    <div class="mb-3">
    <label for="alamat" class="form-label">Tanggal Permohonan</label>
    <input type="text" name="tanggal" class="form-control" placeholder="Nama Lengkap" value="<?php echo $tanggal; ?>" required>
    </div>
    
    <button type="submit" class="btn btn-primary" name="simpan">Simpan</button>
  </form>
</div>

<?php
include("home_bottom.php");
?>