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Lexuma 除舊服務選取紀錄 / Lexuma Removal Service Requisition Form
凡顧客向本公司購買所指定的受管制電器，可要求安排免費除舊服務。請閱讀「除舊服務條款及細則」及了解詳情後，再選取所需服務。請填寫以下表格以作紀錄。

Customers who purchase selected electrical appliances, can request free removal service. Please read "Removal Service Term and Conditions" and understand the details before selecting the required service. Please complete below requisition form for a record.
購買訂單編號 / Order number. : * *
購貨人姓名 / Name of Customer : * *
聯絡電話 / Telephone: * *
購買電器種類 / Category of Purchased Home Appliances : * *
購買電器數量 / Quantity of Purchased Home Appliances : * *
需移走的舊電器種類 / Category of Old Item(s) to be removed : * *
需移走的舊電器數量 / Quantity of Old Item(s) to be removed : * *
請選取所需除舊服務 / Please select your required removal service : * *
補充資料（如有）/ Additional Information (if any) :
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