Products Order Form
Questions marked by * are required.
1. Name of Product Ordered *
2. Packing Quantity *
3. No. of Pouches / Bottles required *
4. Amount intended to be paid. (Price: LOM-C Strong 7.5ml Rs.600, 40ml Rs.2400. Ready DFA CMB 60ml Rs.300, 220ml Rs.1000, QOWDC 10ml Rs.500) *
5. Desired mode of Payment
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?
12. Any other Information/Suggestions *