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Payment Confirmation Form



Confirmation Payment Form

Name *



First


Last

Email *


Confirmation Email *

Phone Number *

Phone Number Will be write at Your Package

Member Number *


Amount Transfer *

Fill Amount that You've Transffered

Payment Proof


Shipping Address : *



Street Address



Address Line 2



City


State / Province / Region



Postal / Zip Code


Country

Payment Option *
 Full Payment ( Total Order + Shipping Fee 
 Total Order
Only 
 Full Payment + Shipping Fee + Tube Fee 
 DP Only 
 Top Up Only 

Payment Date *



MM
/


DD
/


YYYY

Transferred Via Account : *
 BCA 
 Mandiri 
 Paypal 
 Others~ 

Payment Used :


Paypal Email :

* Fill if You Paid with Paypal only

Write List Your Order :


Note For Us :


Please Description Your Others Bank / Payment Used :

Please fill this if you Choose Transfered Via Account Others and Payment Used Others


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