ORDER FORM LEVERRA'S COLLECTION

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NAME *

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EMAIL *

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PHONE NUMBER *

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ADDRESS *

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PRODUCTS ORDER *

State the code or the name of product and the number of unit that you want from us.

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BANK *

eg: Maybank

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PAYMENT DATE *

eg: 01/01/2012

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EVIDENCE OF PAYMENT *

Copy and paste your transaction here

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Submit

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