<!-- Begin Response-O-Matic Form -->
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<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="ceshz66iw8a67kpb" />
<input type="hidden" name="formid" id="formid" value="838896" />
<input type="hidden" name="required_vars" id="required_vars" value="name,field-8f2f380343316ce,email,field-1a1a11067922a55,field-7d33f03a0a38ef4,field-4da019383cddb20" />
</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>Alamat:</strong>
</td>
<td valign="top">
<input type="text" name="field-8f2f380343316ce" id="field-8f2f380343316ce" 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 H/P(1)::</strong>
</td>
<td valign="top">
<input type="text" name="field-1a1a11067922a55" id="field-1a1a11067922a55" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>No H/P (2)::</strong>
</td>
<td valign="top">
<input type="text" name="field-3cd7de2d33098a6" id="field-3cd7de2d33098a6" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Item Code</strong>
</td>
<td valign="top">
<textarea name="field-7d33f03a0a38ef4" id="field-7d33f03a0a38ef4" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Payment</strong>
</td>
<td valign="top">
<input type="radio" name="field-d48f0615f487461" id="field-d48f0615f487461_0" value="CIMB" /> CIMB<br />
<input type="radio" name="field-d48f0615f487461" id="field-d48f0615f487461_1" value="Maybank" /> Maybank<br />
</td>
</tr>
<tr>
<td valign="top">
<strong>Penghantaran</strong>
</td>
<td valign="top">
<input type="radio" name="field-4da019383cddb20" id="field-4da019383cddb20_0" value="Pos Laju" /> Pos Laju<br />
<input type="radio" name="field-4da019383cddb20" id="field-4da019383cddb20_1" value="Pos Laju (Sabah/Sarawak)" /> Pos Laju (Sabah/Sarawak)<br />
<input type="radio" name="field-4da019383cddb20" id="field-4da019383cddb20_2" value="Skynet" /> Skynet<br />
</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 -->
