FoRm TeMPaHan CoKLaT SeDaP

Name :
Email Address :
H/P Number :
Address :
Order : (Please Separate Your Order)
Payment : (Please Email To liyana.mazlan@gmail.com if required) Maybank - 164017098897 (NURUL LIYANA BT MAZLAN)
CIMB Bank - 16010025030521 (NURUL LIYANA BT MAZLAN)
Massage :

Please EMAIL payment detail to me as :
- Name of Payee, Bank, Date, Time, Amount
- Attach of Slip, Receipt, or Print Screen of Online Transfer Receipt.
(Please ATTACH at massage box)
=)


This form powered by Freedback