Order Form

<!-- Begin Freedback Form -->
<!-- DO NOT EDIT YOUR FORM HERE, PLEASE LOG IN AND EDIT AT FREEDBACK.COM -->
<form enctype="multipart/form-data" method="post" action="http://www.freedback.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="dfyyzkbmfu8aivzf" />
<input type="hidden" name="formid" id="formid" value="1185518" />
<input type="hidden" name="required_vars" id="required_vars" value="name,email,field-c90c18c4551f6e3,field-0f4184b29dc3734,field-10d73016bd83348" />
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td valign="top">
<strong>Name:</strong>
</td>
<td valign="top">
<input type="text" name="name" id="name" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Email Address:</strong>
</td>
<td valign="top">
<input type="text" name="email" id="email" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Handphone Number</strong>
</td>
<td valign="top">
<input type="text" name="field-c90c18c4551f6e3" id="field-c90c18c4551f6e3" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Shipping Addres</strong>
</td>
<td valign="top">
<textarea name="field-0f4184b29dc3734" id="field-0f4184b29dc3734" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>Item Names and Code </strong>
</td>
<td valign="top">
<textarea name="field-10d73016bd83348" id="field-10d73016bd83348" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>Payment Method</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-1acbb8b824e61cd[]" id="field-1acbb8b824e61cd_0" value="Maybank" /> Maybank<br/>
<input type="checkbox" name="field-1acbb8b824e61cd[]" id="field-1acbb8b824e61cd_1" value="Bank Islam" /> Bank Islam<br/>
<input type="checkbox" name="field-1acbb8b824e61cd[]" id="field-1acbb8b824e61cd_2" value="CIMB" /> CIMB<br/>
<input type="checkbox" name="field-1acbb8b824e61cd[]" id="field-1acbb8b824e61cd_3" value="BSN" /> BSN<br/>
<input type="checkbox" name="field-1acbb8b824e61cd[]" id="field-1acbb8b824e61cd_4" value="Others please state at note" /> Others please state at note<br/>

</td>
</tr>
<tr>
<td valign="top">
<strong>Note</strong>
</td>
<td valign="top">
<textarea name="field-024b0a8c907e8f8" id="field-024b0a8c907e8f8" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
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<!-- End Freedback Form -->