Mediina Order Form

Order Form STRICTLY FOR SERIUS BUYER ONLY BACK OUTS WILL NOT BE TOLERATE WE ASSUME YOU UNDERSTAND AND AGREE WITH OUR T & C NO RESERVATION, 1ST PAY, 1ST GET CHECK YOUR EMAIL INBOX @ SPAM BOX IN 24 HOUR AFTER YOU FILL UP THE ORDER FORM. WE WILL RESPOND TO YOUR ORDER AS SOON AS POSSIBLE. FOR IMMEDIATE RESPOND, YOU CAN SMS TO 010.4000.244 (H) / 03.4162.0244(O) OR EMAIL ADDRESS : mediinaboutique@gmail.com AFTER FILL UP THE ORDER FORM.
Full Name *
Facebook ID (If Any) *
Email Address *
Phone Number *	### - ### - ####
Shipping Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Item Description, Code (If Any), Quantity & Size: *
Bank Preferred	MAYBANK CIMB BANK ISLAM
Payment Date Time *	01 02 03 04 05 06 07 08 09 10 11 12 MM / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 YYYY 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 HH : 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 MM AM PM AM/PM
Proof of Payment Transactions *
Payment: *	Immediately After Confirmation   Within 24 Hours    Others (Please Put In REMARKS)
Remarks
Confirmation *	I have read, understood and agreed to the Terms and Conditions.

Powered byEMF Online Form

Report Abuse