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<form accept-charset="UTF-8" action="http://www.response-o-matic.com/mail.php" enctype="multipart/form-data" method="post">
<div>
<input id="acctid" name="acctid" type="hidden" value="3z7k4jx0ilex0evj" />
<input id="formid" name="formid" type="hidden" value="1133709" />
<input id="required_vars" name="required_vars" type="hidden" value="name,field-99fb41e2ad61e6b,field-4d39d65b4386f2c,field-f0b25e1f6b5ec9c,field-a5fed972bce54c2,field-65e334121e58b38,field-93985fdc4f626d5,field-09eb105104708ce,field-23343a6260f5a8c" />
</div>
<table border="0" cellpadding="5" cellspacing="5">
<tbody>
<tr>
<td valign="top"><strong>Nama Penuh Pelanggan : </strong>
</td>
<td valign="top"><input id="name" name="name" size="40" type="text" value="" />
</td>
</tr>
<tr>
<td valign="top"><strong>Nama Facebook / Ejen: </strong>
</td>
<td valign="top"><input id="field-99fb41e2ad61e6b" name="field-99fb41e2ad61e6b" size="40" type="text" value="" />
</td>
</tr>
<tr>
<td valign="top"><strong>Alamat Penghantaran : </strong>
</td>
<td valign="top"><textarea cols="40" id="field-4d39d65b4386f2c" name="field-4d39d65b4386f2c" rows="6"></textarea>
</td>
</tr>
<tr>
<td valign="top"><strong>No Tel : </strong>
</td>
<td valign="top"><input id="field-f0b25e1f6b5ec9c" name="field-f0b25e1f6b5ec9c" size="40" type="text" value="" />
</td>
</tr>
<tr>
<td valign="top"><strong>Kod / Saiz / Kuantiti :</strong>
</td>
<td valign="top"><textarea cols="40" id="field-a5fed972bce54c2" name="field-a5fed972bce54c2" rows="6"></textarea>
</td>
</tr>
<tr>
<td valign="top"><strong>Bank Anda :</strong>
</td>
<td valign="top"><input id="field-65e334121e58b38_0" name="field-65e334121e58b38" type="radio" value="CIMB" /> CIMB<br />
<input id="field-65e334121e58b38_1" name="field-65e334121e58b38" type="radio" value="LAIN-LAIN" /> LAIN-LAIN</td>
</tr>
<tr>
<td valign="top"><strong>Amount Yang Dibayar :</strong>
</td>
<td valign="top"><input id="field-93985fdc4f626d5" name="field-93985fdc4f626d5" size="40" type="text" value="" />
</td>
</tr>
<tr>
<td valign="top"><strong>No Rujukan Transaksi</strong>
</td>
<td valign="top"><input id="field-09eb105104708ce" name="field-09eb105104708ce" size="40" type="text" value="" />
</td>
</tr>
<tr>
<td valign="top"><strong>Masa dan Tarikh Pembayaran : </strong>
</td>
<td valign="top"><input id="field-23343a6260f5a8c" name="field-23343a6260f5a8c" size="40" type="text" value="" />
</td>
</tr>
<tr>
<td align="center" colspan="2"><input type="submit" value=" Submit Form " />
</td>
</tr>
</tbody></table>
</form>
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