ORDER FORM

<!-- Begin Response-O-Matic Form -->
<!-- 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="6bitvu8783osduxd" />
<input type="hidden" name="formid" id="formid" value="1059013" />
<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>Name:</strong>
</td>
<td valign="top">
<input type="text" name="name" id="name" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Email Address:</strong>
</td>
<td valign="top">
<input type="text" name="email" id="email" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Contact Number :</strong>
</td>
<td valign="top">
<input type="text" name="field-8ef94246ea5bbbd" id="field-8ef94246ea5bbbd" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Shipping Address :</strong>
</td>
<td valign="top">
<textarea name="field-ba1eff00c127891" id="field-ba1eff00c127891" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>Item Description/Size/Price/Quantity :</strong>
</td>
<td valign="top">
<textarea name="field-fe8aa8aa7fe1ffc" id="field-fe8aa8aa7fe1ffc" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>You are ?</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-d45cc23f205fc12[]" id="field-d45cc23f205fc12_0" value="New Customer" /> New Customer<br/>
<input type="checkbox" name="field-d45cc23f205fc12[]" id="field-d45cc23f205fc12_1" value="Return Customer" /> Return Customer<br/>

</td>
</tr>
<tr>
<td valign="top">
<strong>Payment Method :</strong>
</td>
<td valign="top">
<input type="radio" name="field-6123913772cb357" id="field-6123913772cb357_0" value="Maybank2u" /> Maybank2u<br/>
<input type="radio" name="field-6123913772cb357" id="field-6123913772cb357_1" value="CIMB" /> CIMB<br/>
<input type="radio" name="field-6123913772cb357" id="field-6123913772cb357_2" value="COD" /> COD<br/>

</td>
</tr>
<tr>
<td valign="top">
<strong>Message/Enquiry/Remarks :</strong>
</td>
<td valign="top">
<textarea name="field-9df3c70182a1b51" id="field-9df3c70182a1b51" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
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