@extends('layouts.container') @section('title', 'Pendaftaran Fellowship') @section('title_description', 'Add New') @section('css') @endsection @section('body-class', 'skin-black') @section('content') @if ($errors->any())
@endif {{ Form::open(array('route' => 'fellowshippendaftaran-create-data','role' => 'form','method' => 'PUT', 'files' => true)) }}
{{ Form::submit('Simpan Data', array('class' => 'btn btn-primary')) }}

Registrasi

{{ Form::label('no_registrasi', 'Nomor Registrasi') }} {{ Form::text('no_registrasi', old('no_registrasi'), array('class' => 'form-control no_registrasi bg-light-blue-gradient')) }} {{ Form::hidden('migrate2', '0', array('class' => 'form-control migrate2', 'id' => 'migrate2')) }}
{{ Form::label('nama_lengkap', 'Nama (sesuai STR/ijasah)*') }}
{{ Form::text('nama_lengkap', old('nama_lengkap'), array('class' => 'form-control nama_biodata_dokter')) }}
{{ Form::label('npa_idi', 'NPA IDI*') }} {{ Form::text('npa_idi', old('npa_idi'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('tempat_lahir', 'Tempat Lahir*') }} {{ Form::text('tempat_lahir', old('tempat_lahir'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('tgl_lahir', 'Tanggal Lahir*') }}
{{ Form::text('tgl_lahir', old('tgl_lahir'), array('readonly' => 'readonly', 'class' => 'form-control datepicker')) }}
{{ Form::label('jenis_kelamin', 'Jenis Kelamin*') }} {{ Form::select('jenis_kelamin', $jenis_kelamin, '', array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('alamat', 'Alamat Korespondensi*') }} {{ Form::text('alamat', old('alamat'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('no_telp', 'Nomor Telepon') }} {{ Form::text('no_telp', old('no_telp'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('email', 'Alamat Email') }} {{ Form::text('email', old('email'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('no_hp', 'Nomor HP*') }} {{ Form::text('no_hp', old('no_hp'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('no_hp2', 'Nomor HP Alternatif') }} {{ Form::text('no_hp2', old('no_hp2'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('keterangan', 'Keterangan') }} {{ Form::select('keterangan', $keterangan, '', array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::label('pas_foto', 'Foto* (Format: jpg/jpeg/png, ukuran maksimum 2Mb)') }}
{{ Form::file('pas_foto', array('readonly' => 'readonly','class' => 'form-control')) }}
{{ Form::label('upload_sk_spesialis', 'Upload Data (Format: pdf, ukuran maksimum 2Mb)') }} {{ Form::file('upload_sk_spesialis', array('class' => 'form-control')) }}

Data Fellowship

{{ Form::label('nama_fellowship', 'Nama Fellowship') }}
{{ Form::text('nama_fellowship', old('nama_fellowship'), array('class' => 'form-control nama_fellowship')) }}
{{ Form::label('tempat_rumah_sakit', 'Rumah Sakit Tempat Pendidikan*') }}
{{ Form::text('tempat_rumah_sakit', '', array('class' => 'form-control tempat_rumah_sakit')) }}
{{ Form::label('tgl_mulai', 'Mulai Pendidikan*') }}
{{ Form::text('tgl_mulai', old('tgl_mulai'), array('class' => 'form-control datepicker tgl_mulai')) }}
{{ Form::label('tgl_lulus', 'Selesai Pendidikan') }}
{{ Form::text('tgl_lulus', old('tgl_lulus'), array('class' => 'form-control datepicker')) }}

PAPDI Cabang

{{ Form::label('papdi_cabang', 'Papdi Cabang') }} {{ Form::text('papdi_cabang', old('papdi_cabang'), array('readonly' => 'readonly', 'class' => 'form-control')) }}
{{ Form::close() }} @stop @section('js') @stop