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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="zfviaz487lf6saf6" />
<input type="hidden" name="formid" id="formid" value="1083632" />
<input type="hidden" name="required_vars" id="required_vars" value="name,field-89420c914ea2306,email,field-4491880632ac37f,field-2589b069947e27b,field-b793f266dda0185,field-f6d1b96460ac267,field-af14e41c35f83f4" />
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td valign="top">
<strong>Name Penuh : </strong>
</td>
<td valign="top">
<input type="text" name="name" id="name" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Nombor Telefon :</strong>
</td>
<td valign="top">
<input type="text" name="field-89420c914ea2306" id="field-89420c914ea2306" 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>Alamat Penghantaran : </strong>
</td>
<td valign="top">
<textarea name="field-4491880632ac37f" id="field-4491880632ac37f" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Item Order dan Kuantiti</strong>
</td>
<td valign="top">
<textarea name="field-2589b069947e27b" id="field-2589b069947e27b" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Jumlah Item</strong>
</td>
<td valign="top">
<input type="text" name="field-b793f266dda0185" id="field-b793f266dda0185" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Pembayaran Menggunakan : </strong>
</td>
<td valign="top">
<input type="radio" name="field-f6d1b96460ac267" id="field-f6d1b96460ac267_0" value="CIMB 07180061022524" /> CIMB 07180061022524<br/>
<input type="radio" name="field-f6d1b96460ac267" id="field-f6d1b96460ac267_1" value="MAYBANK 102091002901" /> MAYBANK 102091002901<br/>
<input type="radio" name="field-f6d1b96460ac267" id="field-f6d1b96460ac267_2" value="BANK ISLAM 07016020438718" /> BANK ISLAM 07016020438718<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Pembayaran Melalui</strong>
</td>
<td valign="top">
<input type="radio" name="field-af14e41c35f83f4" id="field-af14e41c35f83f4_0" value="Cash Deposit Machine (CDM)" /> Cash Deposit Machine (CDM)<br/>
<input type="radio" name="field-af14e41c35f83f4" id="field-af14e41c35f83f4_1" value="Online Banking" /> Online Banking<br/>
<input type="radio" name="field-af14e41c35f83f4" id="field-af14e41c35f83f4_2" value="Kaunter Bank" /> Kaunter Bank<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Pertanyaan/Pesanan</strong>
</td>
<td valign="top">
<textarea name="field-a4c64a76d5e9ab2" id="field-a4c64a76d5e9ab2" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
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