<!-- DO NOT EDIT YOUR FORM HERE, PLEASE LOG IN AND EDIT AT RESPONSE-O-MATIC.COM -->
<form enctype="multipart/form-data" method="post" action="http://www.response-o-matic.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="i1hzogjx6a6cm4kc" />
<input type="hidden" name="formid" id="formid" value="1267261" />
<input type="hidden" name="required_vars" id="required_vars" value="name,email" />
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td valign="top">
<strong>Nama:</strong>
</td>
<td valign="top">
<input type="text" name="name" id="name" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Alamat Email:</strong>
</td>
<td valign="top">
<input type="text" name="email" id="email" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Alamat Penghantaran:</strong>
</td>
<td valign="top">
<textarea name="field-b4f0b6dfc3c70bb" id="field-b4f0b6dfc3c70bb" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Nombor Telefon:</strong>
</td>
<td valign="top">
<input type="text" name="field-2f4ed575eaae7ca" id="field-2f4ed575eaae7ca" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Produk Yang Ingin Dibeli: contoh Mince 2 botol</strong>
</td>
<td valign="top">
<textarea name="field-64a5f2c402a0ef3" id="field-64a5f2c402a0ef3" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Nama Bank: contoh Maybank</strong>
</td>
<td valign="top">
<input type="text" name="field-2021e9270115ef2" id="field-2021e9270115ef2" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Tarikh Bayaran : contoh 11/4/2015</strong>
</td>
<td valign="top">
<input type="text" name="field-60408ac8c26560f" id="field-60408ac8c26560f" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Masa Bayaran: contoh 12:39 pm</strong>
</td>
<td valign="top">
<input type="text" name="field-4d6d44618d02e20" id="field-4d6d44618d02e20" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Nyatakan bukti pembayaran: (Jika ada)</strong>
</td>
<td valign="top">
<textarea name="field-bdd7ee50a0bc997" id="field-bdd7ee50a0bc997" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
<br><center><font face="Arial, Helvetica" size="1"><b>
Form provided by <a href="http://www.response-o-matic.com">Freedback</a>.
</b></font></center>
<!-- End Response-O-Matic Form -->
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