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WEAK ERECTION ORDER FORM
PLEASE SUPPLY THE NECESSARY INFORMATION FOR OUR AGENT TO EASILY CONTACT YOU FOR DELIVERY
If you know that you're not ready to receive the parcel whenever you're called by our agent, please do not fill out the order form
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* Indicates required question
FULL NAME
*
Your answer
DELIVERY ADDRESS * *
*
Your answer
DATE OF DELIVERY
*
MM
/
DD
/
YYYY
STATE/CITY * *
*
Your answer
PHONE NUMBER * *
*
Your answer
WHATSAPP NUMBER
*
Your answer
Email/Gmail address
*
Your answer
SELECT YOUR PREFERRED BOTTLES PACKAGE
*
Choose
ONE BOTTLE 390 GHC
TWO BOTTLES 580 GHC
FULL PACKAGE 780 GHC
WHEN DO YOU WANT US TO DELIVER THE PACKAGE
*
WITHIN 14
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