| ORDER BY |
DELIVER TO |
| Company:______________________________ |
Name:____________________________________ |
| Name:____________________________ |
Delivery address:__________________________________ |
| Address:______________________________ |
___________________________________________ |
| __________________________________ |
___________________________________________ |
| __________________________________ |
Email address:__________________________ |
| Email address:__________________________ |
Tel no.:______________________________ |
| Tel no.:__________________________ |
Order product number:________________________ |
| Fax no.:__________________________ |
Delivery date and Time:__________________AM/PM |
| Member: Yes / No |
|
| Member Name: |
|