Dec 7, 2012

Payment Form

Full Name *

Email *

Transfer ke *
 BCA 
 BRI 
Transfer via *

Dari Rekening Atas Nama *

*jika lewat setor tunai/teller, harap tulis nama penyetor
Nominal Transfer *

*jumlah yang dibayarkan
Tanggal Transfer *

DD
/
MM
/
YYYY
Bukti Transfer

Order Item

Notes

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Order Form

Full Name *

Email *

Phone Number *

Address *
Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Transfer Via *
 BCA 
 BRI 
 Other 
Order Item *

*tulis pesanan Anda beserta jumlah barang yang dipesan. Jangan lupa sertakan size, warna, atau type (jika perlu)
Notes

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