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MALE IMPOTENCE/INFERTILITY FORM
PLS SUPPLY THE NECESSARY INFORMATION FOR OUR AGENT TO EASILY CONTACT YOU FOR DELIVERY
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FULL NAME
*
Your answer
DELIVERY ADDRESS
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Your answer
DATE OF DELIVERY
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MM
/
DD
/
YYYY
STATE/CITY
*
Your answer
PHONE NUMBER
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Your answer
WHATSAPP NUMBER
*
Your answer
EMAIL/GMAIL ADDRESS
*
Your answer
PRODUCTS PACK
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Full pack #67,500
4in1 pack 47,500
Please note: your Delivery date must be between 25days otherwise order might not be processed
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Yes I agreed and I have adjusted my delivery date
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