ORDER FORM

CIMB acc: 12380000852206

Maybank acc: 164397972835
Ahmad Zarique Kysar
Notice: Please make your transaction before you fill in the form.

FOR INQUIRIES, CALL
012-3164473 (zarique)


Product will be send via post to your specific address.

FULL NAME:
Email Address:
ADDRESS:
PHONE:
CHOOSE YOUR PREFERRED PRODUCT:	- AQURA SYAMPOO TUDUNG 300ml RM70 AQURA SYAMPOO TUDUNG 30ml RM10 Aqura soap FACIAL (RM65) Aqura soap BATH (RM30) RAFA energy pendant (RM400) Juice EPITRA (RM170) Revo Cafe (RM30)
QTY:	- 1 2 3 4 5 6 7 8 9 10
CHOOSE YOUR PREFERRED PRODUCT:	- AQURA SYAMPOO TUDUNG 300ml RM70 AQURA SYAMPOO TUDUNG 30ml RM10 Aqura soap FACIAL (RM65) Aqura soap BATH (RM30) RAFA energy pendant (RM400) Juice EPITRA (RM170) Revo Cafe (RM30)
QTY:	- 1 2 3 4 5 6 7 8 9 10
PROMOTION PACK:	(bath+facial)one set RM90 (3+3) set bath and facial RM250 (6+6) set bath and facial RM500 3 pendant RM950 6 pendant RM2000 10 box revo cafe + FREE 2 boxes RM300
QTY:	- 1 2 3 4 5 6 7 8 9 10
YOUR REFERENCE (this is to ensure that which agent you have referred with ):	- zarique (012-3164473) fikri (019-3726269) yatty (017-6884821) affan (017-5202287) syahmi (012-6685949) ellyza (017-6404906)
TOTAL:
DATE BANK IN:
BANK NAME:
BANK RESIT NO. :

NOTICE: PLEASE TYPE "I HAVE MADE ONLINE ORDER" AND SEND TO 012-3164473...WE WILL CHECK YOUR ONLINE ORDER STATUS..