Order Form

<!-- Begin Response-O-Matic Form -->
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<form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="odndh4uj4i2gyn0d" />
<input type="hidden" name="formid" id="formid" value="1179165" />
<input type="hidden" name="required_vars" id="required_vars" value="name,email" />
</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>Address:</strong>
</td>
<td valign="top">
<textarea name="field-6a2eeebe5e36d0a" id="field-6a2eeebe5e36d0a" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>Product/item:</strong>
</td>
<td valign="top">
<textarea name="field-17e67279201d643" id="field-17e67279201d643" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>Phone Number:</strong>
</td>
<td valign="top">
<input type="text" name="field-b221c8862d8a15d" id="field-b221c8862d8a15d" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Payment Account(siti umairah fazli):</strong>
</td>
<td valign="top">
<input type="radio" name="field-8f02a9a0cd0f445" id="field-8f02a9a0cd0f445_0" value="cimb-07041104472526" /> cimb-07041104472526<br/>
<input type="radio" name="field-8f02a9a0cd0f445" id="field-8f02a9a0cd0f445_1" value="maybank-157410112039" /> maybank-157410112039<br/>

</td>
</tr>
<tr>
<td valign="top">
<strong>Date/Time/transfer script</strong>
</td>
<td valign="top">
<textarea name="field-c0f96c5a50d8211" id="field-c0f96c5a50d8211" 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 Response-O-Matic Form -->