Products Order Form
Questions marked by * are required.
1.
Name of Product Ordered *
-
LOM-C Strong
LOM C CD
DFA 6ml
DFA CDP 300mg
QOWDC
2.
Packing Quantity *
-
LOM-C Strong 7.5ml
LOM C CD 6ml
QOWDC 8ml
DFA CMB 6ml
DFA C CDP 300mg
3.
No. of Pouches / Bottles required *
4.
Amount intended to be paid. (Price: LOM-C Strong 7.5ml Rs.600, LOM C CD 6ml Rs.900, DFA CMB 6ml Rs.60, DFA C CDP 300mg Rs.195;QOWDC 8ml Rs.500) *
5.
Desired mode of Payment
-
Through Bank Transfer
PhonePay
PayTm
online Payment
QR Code
other mode
6.
Your Name *
7.
Email: *
8.
Full Postal Address with Pin Code *
9.
Mobile/Phone Number *
10.
What Courier service is operating in your location? *
Professional Courier
Shree Tirupati Couriers
11.
Do you want to become an Agent for Our Products?
-
Yes
No
No idea
12.
Any other Information/Suggestions *