MAQUI-SUPERBERRY-KBYNETWORK

Associate Application and Product Order Form
Full Name (as in Bank Account) :
Nama Penuh (seperti dalam Akaun Bank) :
姓名 (洋) (根据银行户口) : 		*
My Bank Account: Name of Bank: * Account No : *
First Name/Nickname :
Gender / Jantina / 性别 : Male / Lelaki / 男   Female / Perempuan / 女
Mykad No. : *
Phone : Mobile           *
E-mail : *
House No. & Street :
Alamat (No. & Nama Jalan) :
住家地址 : 		*
City : / Bandar / 城市 : State : / Negeri / 州 : * Post Code : *
Country / Negara / 国家 : *

Order
Quantity Pricing per bottle: RM140 (1 bottle price); RM130 (6 bottles + above price) RM90 (24 bottles + above price)
ITEM QTY AMOUNT (RM)
1. Maqui SuperBerry Liquid 480ml
2. Maqui SuperFruit Energy Powder 90g
3. Maqui WholeFruit Freezedried Powder 90g
Grand Total (RM) :
Quantity prices apply to mixture of all three items. Free delivery to Peninsula Malaysia only.
For other destinations, additional shipping charges apply.

Shipping Address (if different from above)
Alamat untuk menghantar pesanan (kalau lain dari atas)
送货地址 (如有)
Full Name :
Nama Penuh :
姓名 (洋) :
House No. & Street :
Alamat (No. & Nama Jalan) :
住家地址 :
City : / Bandar / 城市 : State : / Negeri / 州 : Post Code :
Country / Negara / 国家 :
Tel No :
I would like to pay via :
Saya ingin bayar melalui :
我想付账通过 :
Our PayPal A/C: dakhoos@gmail.com
Our Bank Account: MBB No. 507040209922,
Name: Khoo Boo Yeang, Tel: 012 483 6281
My Introducer : / Pencadang / 推荐人 :
Please send me details of autoshipment       Please send me Newsletter
Where I found your website :

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KBY Network Sdn. Bhd. 19 David Chen Gardens, 11400 Air Itam, Penang, Malaysia. Tel: +6012 483 6281 Fax: +604 827 3415
Email: dakhoos@gmail.com    Website: http://penangresort.com/mymaqui