ORDER FORM

Are you member:	Yes No
Member ID No: (If you are member)
Full Name:
I/C No:(for member registeration)
Email Address:
Contact No:
Shipping Address:
Orders:	Order No 1-Alpha Lipid SD II (member RM150, non-member RM180) Order No 2-Alpha Lipid Lifeline (member RM150, non-memeber RM180) Order No 3-Omega CoQ10 (member RM150, non-member RM180) Order No 4-Fiber Max (member RM110, non-member RM138) Order No 5-Ketostick (member RM20, non-member RM27)
Quantity for order No:
Please sumbit your order form and sms to 012-2244275 for notification. We will email you the amount and courier charges to bank in. Please pay your order via MAYBANK ACCOUNT A/C 114066590565 LETCHUMY A/P DORASAMY. Thank you. Any information please contact me at 012-2244275 or email at ezyshopinsd@gmail.com

Put a website form like this on your site.