Address : Majapahit St. No. 46 Legian
- Kuta - Bali - Indonesia
Phone : +62 361 756 264
Facsimile : +62 361 762 593
Order Form
Please print this form to order and send by fax to us
 
Customer Payment And Order Status
 Name:  
 Address:  
 Zip Code:  
 Phone:  
 Facsimile:  
 Email:  
OrderId:  
Received:
 
 Status:  
 Amount:  
 Deposit:  
Shipment Method
Sea FreightAir FreightDHLOther
Payment Method
Bank TransferringCashCredit Card
Product Order
No. Code Description Quantity Unit Price Amount
1     
2     
3     
4     
5     
6     
7     
8     
9     
10     
11     
12     
13     
 
Total Amount
  
Deposit
  
Balance
  
 

Notes
 

Signature

 

 

 

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