QTY       DESCRIPTION         PRODUCT CODE    UNIT PRICE    HANDLING       TOTAL
           (include size)                          (RM)                  (including handling)

 
 
 
 
 
 
 
 
 
 
 
 					                           TOTAL 
                 BILLING BY FAX OR MAIL
     Credit card VISA MasterCard 
 Cardholder name 
     Card number 
 Expiration date 

By Mail          I have enclosed my Cheque/Money Order/Bank Draft

                 No.  for RM 

                 Made Payable to
                 PACIFIC & ORIENT DISTRIBUTION SDN BHD

  SHIPPING
  Street address  
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal code 
         Country 

               BILLING

      First name 
       Last name 
  Middle initial 
  Address        
   City          
  State/Province 
 Zip/Postal code 
         Country 
      Home Phone 
             FAX 

Optional Information
   Date of Birth   I/C No:
   Occupation      Marital Status

Would you like to receive brochures on other products? Please Make A SelectionYesNo

THIS CONTRACT IS SUBJECT TO A COOLING - OFF PERIOD OF TEN WORKING DAYS
                                                  for P&O Distribution

x______________________   X__________________    X__________________
Card Memeber Signature    Purchaser's Signature  Vendor's Signature
Date:__________________   Date:________________

Delivery will normally take 2 weeks but may require 3 to 4 weeks depending on stock availability. All orders are subject to acceptance and availability of stock deliveries will be made only within Peninsular Malaysia. No deliveries will be made to P.O. Box address. All products can be viewed at No:2 Jalan Kamunting, Off Jalan Dang Wangi,50300 Kuala Lumpur.

Print and Mail or Fax To:*
 
Pacific & Orient Distribution SDN BHD
16th Floor, Wisma Bumi Raya
No 10, Jalan Raja Laut
50350 Kuala Lumpur, Malaysia
Telephone Number: 03 2697 9877 Fax Number : 03 2698 6201

 *Please note this form MUST be printed then mailed or faxed