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="tzoq1baxg93kx7oh" />
<input type="hidden" name="formid" id="formid" value="1145628" />
<input type="hidden" name="required_vars" id="required_vars" value="name,email,field-fe370e12ba57a67" />
</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>No hp</strong>
</td>
<td valign="top">
<input type="text" name="field-fe370e12ba57a67" id="field-fe370e12ba57a67" size="40" value="" />

</td>
</tr>
<tr>
<td valign="top">
<strong>Code &amp; Quantity</strong>
</td>
<td valign="top">
<textarea name="field-78463cd34d5bb5d" id="field-78463cd34d5bb5d" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>Delivery Address</strong>
</td>
<td valign="top">
<textarea name="field-8f922f6d6a91e1c" id="field-8f922f6d6a91e1c" rows="6" cols="40"></textarea>

</td>
</tr>
<tr>
<td valign="top">
<strong>Notes &amp; Messages</strong>
</td>
<td valign="top">
<textarea name="field-c62b98294f3c043" id="field-c62b98294f3c043" 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>
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</b></font></center>
<!-- End Response-O-Matic Form -->