Order form for delivery miner

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please fill another form if you want to buy a host miner https://docs.google.com/forms/d/1moJLc8RH27CduZodV0RD-jrRP21X6IeEQU0Vkp7auZA/viewform

Forum ID *

please filled with your forum id in bitcointalk.org, if you donot have one, you can leave this blank or filled with your real name

Contact email *

filled with your email address for contact

Miner type *

please chose the type of the miner

A1 chip Dragon 1T bitcoin miner---1499$

Antminer S3 bitcoin miner(2 units)--1249$

A2 chip 86M scrypt miner--5099$

A2 chip 60M scrypt miner--3899$

A2 chip 30M scrypt miner--1799$

B2 chip 30M scrypt miner--2199$

SF 28M scrypt miner--1199$

SF 70M scrypt miner-6099$

Zeus 28M scypt miner-999$

ORDER Quantity *

filled with how many units you ordered

price($) *

filled with the price you pay

Discount *

if you have any discount, filled here, if you don't have any discount, write 0 here

Real time exchange ratio of btc/usd from btc-e

if you pay me via btc, please filled real time exchange ratio of btc/usd from btc-e

payment method *

btc directly--1BNwtEPanWJ9VLdiJebtykQJgk3eEZFh52

paypal(4%fee)--peicaili@gmail.com

wire transfer

ltc directly--Lbhtf2fgorT6W3U4K3yKRAYLHFYg2idrxW

price in btc or ltc

transaction ID

please paste the transaction ID here if your payment method is btc

paypal account

please fill your paypal account if your payment method is paypal

receiver name *

contact phone *

address *

city *

Province

fill in your province if your country is usa or canada

postcode

country *

payment status *

special requirment

please mark your special requirement towards invoice and other thing here

Reference

if you have any reference, please specify their name here

Submit

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