Order Form

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Order Form

	* Name :
	* Email :
	* Tel. # :	- -
	Order Information :
	Product Serial # :	(See description of required. LCD)
	* LCD Part # :	(See description of required. LCD)
	* Quantity :	(Select the quantity of LCDs you wish to order)
	* Price :	(See description of required. LCD)
	* Connector Type : (Please check one)
	* Country :	(Select the country for shipment)
	Country Code :	(Write a Code for country e.g CN for China or PAK for Pakistan etc.)
	* First Piece US $ :	(Find the price for shipping to your country from shipping details)
	Additional Pcs. :	(Fill if ordering more than 1 LCD)
	* Total Shipping in US $ :		(Write in the format 37.00)
	* Total Cost in US $ :		(Write in the format 37.00)
	* Payment Option :
	Card Type :	(VISA, MC, AMEX, Discovery & JCB accepted)
	Card Number :	(13-16 Digits Credit Card Number)
	Expiry Date :	(Month) (Year)
	3-Digit Code :	(3 or 4 Digit Code at back of card)
	Name on Card :	(First Name Last Name)
	Billing Address :
	City :
	State :
	Zip / Postal Code :
	Country :
	* Ship Address : (Please do mention whether same as billing address or not)

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