INFECTION PACK ORDER FORM

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PLEASE, SUPPLY THE CORRECT INFORMATION,FOR OUR COURIER AGENT TO EASILY CONTACT YOU FOR DELIVERY

* Indicates required question

FULL NAME *

Your answer

DATE OF DELIVERY *

MM

/

DD

/

YYYY

DELIVERY ADDRESS *

Your answer

STATE/CITY
*

Your answer

PHONE NUMBER *

Your answer

WHATSAPP NUMBER *

Your answer

GMAIL/MAILING ADDRESS *

Your answer

PLEASE SELECT YOUR COUNTRY COST PRICE *

Choose

MALE 39,500 NAIRA

FEMALE 39,500

YOUR DELIVERY DATE MUST BE UNDER 20 DAYS, kindly adjust if you have filled over 20days* *

I AM READY TO RECEIVE MY PARCEL WHEN BEING CONTACTED

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