form action="llena_tabla_new_inter.php" method="post" name="form1" class="Estilo10" id="form1">
<table width="669" border="0" align="center">
<tr>
<td width="90"><span class="Estilo10 Estilo20"><strong>Nombre</strong></span></td>
<td width="196">
<label>
<input name="nombre" type="text" class="Estilo10" id="nombre" size="37" />
</label> </td>
<td width="104"> </td>
<td width="261"> </td>
</tr>
<tr>
<td><span class="Estilo10 Estilo20"><strong>Sexo</strong></span></td>
<td>
<label>
<select name="sexo[]" class="Estilo10" id="sexo[]">
<option value="femenino">Femenino</option>
<option value="masculino">Masculino</option>
</select>
</label> </td>
<td><span class="Estilo10 Estilo20"><strong>Estado Civil</strong></span></td>
<td>
<label></label>
<label>
<select name="estacivil[]" class="Estilo10" id="estacivil[]">
<option value="casado">Casado</option>
<option value="soltero">Soltero</option>
<option value="viudo">Viudo</option>
<option value="union libre" selected="selected">Union libre</option>
<option value="separado">Separado</option>
</select>
</label> </td>
</tr>
<tr>
<td><span class="Estilo21">Edad</span></td>
<td><input name="edad" type="text" class="Estilo10" id="edad" /></td>
<td><span class="Estilo20"><strong>Fecha Nacimiento</strong></span></td>
<td><label></label> <input name="naci" type="text" class="Estilo10" id="naci" value="" /> </td>
</tr>
<tr>
<td><span class="Estilo21">Tipo de Contacto</span></td>
<td><select name="tipo_contact[]" class="Estilo10" id="tipo_contact[]">
<option value="llamada">Llamada Fijo</option>
<option value="correo">Correo</option>
<option value="chat">Chat</option>
<option value="personal">Personal</option>
<option value="mensaje_texto">Mensaje de texto</option>
<option value="llamada_celu">Llamada Celular</option>
<option value="red_social">Red Social</option>
</select></td>
<td><span class="Estilo10 Estilo20"><strong>Correo Electronico</strong></span></td>
<td>
<label>
<input name="mail" type="text" class="Estilo10" id="mail" size="35" />
</label> </td>
</tr>
<tr>
<td><span class="Estilo21">Pais</span></td>
<td><label>
<?php generaPaises(); ?>
</label></td>
<td><span class="Estilo10 Estilo20"><strong>Estado</strong></span></td>
<td><label>
<select name="estados[]" disabled="disabled" class="Estilo10" id="estados">
<option value="0">Selecciona opción...</option>
</select>
</label> </td>
</tr>
<tr>
<td><span class="Estilo21">Ciudad</span></td>
<td><input name="ciudad" type="text" class="Estilo10" id="ciudad" /></td>
<td><span class="Estilo20"><strong>Profesion</strong></span></td>
<td><label></label> <select name="profe[]" class="Estilo10" id="profe[]" >
<?php foreach($regis as $v){ ?>
<option value="<?php echo $v[0] ?>"><?php echo $v[0] ?> </option>
<?php }?>
</select></td>
</tr>
<tr>
<td><span class="Estilo21">Telefono</span></td>
<td><input name="tele" type="text" class="Estilo10" id="tele" /></td>
<td><span class="Estilo10 Estilo20"><strong>Celular</strong></span></td>
<td><label>
<input name="celu" type="text" class="Estilo10" id="celu" />
</label> </td>
</tr>
<tr>
<td><span class="Estilo10 Estilo20"><strong>Donde nos vio</strong></span></td>
<td><label>
<select name="donde_ns_vio[]" class="Estilo10" id="donde_ns_vio[]">
<option value="enlace">Enlace</option>
<option value="directv">DirecTV</option>
<option value="amigo">Amigo</option>
<option value="familiar">Familiar</option>
<option value="correo">Correo</option>
<option value="red social">Red Social</option>
<option value="web">Web</option>
</select>
</label> </td>
<td height="31"><span class="Estilo10 Estilo20"><strong>Necesidad</strong></span></td>
<td><label>
<select name="necesidad[]" class="Estilo10" id="necesidad[]">
<option value="oracion">Oracion</option>
<option value="consejeria">Consejeria</option>
<option value="sugerencia">Sugerencia</option>
<option value="pregunta">Pregunta</option>
<option value="testimonio">Testimonio</option>
<option value="opinion">Opinion</option>
<option value="solicitud">Solicitud</option>
<option value="siembra">Siembra</option>
<option value="critica">Critica</option>
<option value="otro">Otro</option>
</select>
</label> </td>
</tr>
<tr>
<td height="29"><span class="Estilo21">Atendido por</span></td>
<td><input name="atendido_por" type="text" class="Estilo10" id="atendido_por" /></td>
<td colspan="2" align="center" valign="middle"><div align="left"><span class="Estilo10 Estilo20"><strong>
<input type="radio" name="contacto" id="contacto" value="llamada" />
Llamada
<input type="radio" name="contacto" id="contacto" value="concejeria" />
Consejeria
<input type="radio" name="contacto" id="contacto" value="pastoreo" />
</strong><strong> Pastoreo </strong></span> </div>
<div align="left" class="Estilo10 Estilo21">
<div align="center"></div>
</div></td>
</tr>
<tr>
<td><span class="Estilo21">Hora:</span></td>
<td>
<label></label>
<select name="hora[]" class="Estilo10" id="hora[]">
<option value="">-Seleccione Hora -</option>
<option value="5:00 am">5:00 am</option>
<option value="5:30 am">5:30 am</option>
<option value="6:00 am">6:00 am</option>
<option value="6:30 am">6:30 am</option>
<option value="7:00 am">7:00 am</option>
<option value="7:30 am">7:30 am </option>
<option value="8:00 am">8:00 am</option>
<option value="8:30 am">8:30 am</option>
<option value="9:00 am">9:00 am</option>
<option value="9:30 am">9:30 am</option>
<option value="10:00 am">10:00 am</option>
<option value="10:30 am">10:30 am</option>
<option value="11:00 am">11:00 am</option>
<option value="11:30 am">11:30 am</option>
<option value="">-------------</option>
<option value="12:00 m">12:00 m</option>
<option value="12:30 m">12:30 m</option>
<option value="1:00 pm">1:00 pm</option>
<option value="1:30 pm">1:30 pm</option>
<option value="2:00 pm">2:00 pm</option>
<option value="2:30 pm">2:30 pm</option>
<option value="3:00 pm">3:00 pm</option>
<option value="3:30 pm">3:30 pm</option>
<option value="4:00 pm">4:00 pm</option>
<option value="4:30 pm">4:30 pm</option>
<option value="5:00 pm">5:00 pm</option>
<option value="5:30 pm">5:30 pm</option>
<option value="6:00 pm">6:00 pm</option>
<option value="6:30 pm">6:30 pm</option>
<option value="7:00 pm">7:00 pm</option>
<option value="7:30 pm">7:30 pm</option>
<option value="8:00 pm">8:00 pm</option>
<option value="8:30 pm">8:30 pm</option>
</select></td>
<td height="29"><span class="Estilo20"><strong>Fecha</strong></span></td>
<td><label>
<input name="fecha" type="text" class="Estilo10" id="fecha" />
</label></td>
</tr>
<tr>
<td height="33"><span class="Estilo10 Estilo20"><strong>Descripcion</strong></span></td>
<td colspan="3" rowspan="3"><label>
<textarea name="descrip" id="descrip" cols="45" rows="5"></textarea>
</label>
<input type="hidden" name="pais" id="pais" /></td>
</tr>
<tr>
<td height="33"> </td>
</tr>
<tr>
<td height="22"> </td>
</tr>
<tr>
<td height="33"> </td>
<td colspan="3"><label>
<style type="text/css">
.boton{
font-size:10px;
font-family:Geneva, Arial, Helvetica, sans-serif;
color: #000000;
background: #FFFFFF;
width:100px;
height:25px;
}
</style>
<input type="submit" name="guardar" id="guardar" value="Guardar" class="boton" />
<input type="button" name="restablecer" id="restablecer" value="Restablecer" class="boton" />
</label></td>
</tr>
</table>
<p align="center"> </p>
</form>