<form id="emf-form" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/e89lOg51d1BX0o4245ey4NdT7" name="emf-form">
<table style="text-align: left; color: rgb(255, 255, 255);" bg="" border="0" cellpadding="2" cellspacing="0">
<tbody><tr>
<td style="" colspan="2">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b style="font-size: 20px;">Invoice Request</b>
</span>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_0" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>Name</b></span>
</td>
</tr>
<tr>
<td id="td_element_field_0" style="">
<table border="0" cellpadding="0" cellspacing="0">
<tbody><tr>
<td style="padding-left: 0pt; padding-right: 3px;" align="center">
<input style="width: 60px;" value="" id="element_0_2" name="element_0[]" class="validate[optional]" type="text" />
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >First</span>
</td>
<td style="padding-left: 0pt;" align="center">
<input style="width: 100px;" value="" id="element_0_3" name="element_0[]" class="validate[optional]" type="text" />
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >Last</span>
</td>
</tr>
</tbody></table>
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);"></div>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_1" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>No.HP</b></span> <span style="color:red;"><small>*</small></span>
</td>
</tr>
<tr>
<td id="td_element_field_1" style="">
<input id="element_1" name="element_1" value="" size="30" class="validate[required]" type="text" />
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);"></div>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_2" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>Address</b></span> <span style="color:red;"><small>*</small></span>
</td>
</tr>
<tr>
<td id="td_element_field_2" style="">
<table border="0" cellpadding="0" cellspacing="0" width="100%">
<tbody><tr>
<td colspan="2" style="padding-left: 0pt;">
<input value="" style="width: 99%;" id="element_2_1" name="element_2[]" class="validate[required]" type="text" />
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >Street Address</span>
</td>
</tr>
<tr style="">
<td colspan="2" style="padding-left: 0pt;">
<input value="" style="width: 99%;" id="element_2_2" name="element_2[]" class="validate[optional]" type="text" />
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >Address Line 2</span>
</td>
</tr>
<tr>
<td style="width: 50%; padding-left: 0pt;">
<input value="" style="width: 99%;" id="element_2_3" name="element_2[]" class="validate[required]" type="text" />
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >City</span>
</td>
<td style="width: 50%; padding-left: 5px;">
<input value="" style="width: 99%;" id="element_2_4" name="element_2[]" class="validate[required]" type="text" />
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >State / Province / Region</span>
</td>
</tr>
<tr>
<td style="width: 50%; padding-left: 0pt;">
<input value="" style="width: 99%;" id="element_2_5" name="element_2[]" class="validate[required]" type="text" />
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >Postal / Zip Code</span>
</td>
<td style="width: 50%; padding-left: 5px;">
<select style="width: 100%;" id="element_2_6" name="element_2[]" class="validate[required]"> <optgroup label="North America"></optgroup> <option value="Antigua and Barbuda" /> Antigua and Barbuda <option value="Aruba" /> Aruba <option value="Bahamas" /> Bahamas <option value="Barbados" /> Barbados <option value="Belize" /> Belize <option value="Canada" /> Canada <option value="Cook Islands" /> Cook Islands <option value="Costa Rica" /> Costa Rica <option value="Cuba" /> Cuba <option value="Dominica" /> Dominica <option value="Dominican Republic" /> Dominican Republic <option value="El Salvador" /> El Salvador <option value="Grenada" /> Grenada <option value="Guatemala" /> Guatemala <option value="Haiti" /> Haiti <option value="Honduras" /> Honduras <option value="Jamaica" /> Jamaica <option value="Mexico" /> Mexico <option value="Netherlands Antilles" /> Netherlands Antilles <option value="Nicaragua" /> Nicaragua <option value="Panama " /> Panama <option value="Puerto Rico " /> Puerto Rico <option value="Saint Kitts and Nevis" /> Saint Kitts and Nevis <option value="Saint Lucia" /> Saint Lucia <option value="Saint Vincent and the Grenadines" /> Saint Vincent and the Grenadines <option value="Trinidad and Tobago" /> Trinidad and Tobago <option value="United States" /> United States <optgroup label="South America"></optgroup> <option value="Argentina" /> Argentina <option value="Bolivia" /> Bolivia <option value="Brazil" /> Brazil <option value="Chile" /> Chile <option value="Colombia" /> Colombia <option value="Ecuador" /> Ecuador <option value="Guyana" /> Guyana <option value="Paraguay" /> Paraguay <option value="Peru" /> Peru <option value="Suriname" /> Suriname <option value="Uruguay" /> Uruguay <option value="Venezuela" /> Venezuela <optgroup label="Europe"></optgroup> <option value="Albania" /> Albania <option value="Andorra" /> Andorra <option value="Armenia" /> Armenia <option value="Austria" /> Austria <option value="Azerbaijan" /> Azerbaijan <option value="Belarus" /> Belarus <option value="Belgium" /> Belgium <option value="Bosnia and Herzegovina" /> Bosnia and Herzegovina <option value="Bulgaria" /> Bulgaria <option value="Croatia" /> Croatia <option value="Cyprus" /> Cyprus <option value="Czech Republic" /> Czech Republic <option value="Denmark" /> Denmark <option value="Estonia" /> Estonia <option value="Faroe Islands" /> Faroe Islands <option value="Finland" /> Finland <option value="France" /> France <option value="Georgia" /> Georgia <option value="Germany" /> Germany <option value="Greece" /> Greece <option value="Hungary" /> Hungary <option value="Iceland" /> Iceland <option value="Ireland" /> Ireland <option value="Italy" /> Italy <option value="Latvia" /> Latvia <option value="Liechtenstein" /> Liechtenstein <option value="Lithuania" /> Lithuania <option value="Luxembourg" /> Luxembourg <option value="Macedonia" /> Macedonia <option value="Malta" /> Malta <option value="Moldova" /> Moldova <option value="Monaco" /> Monaco <option value="Montenegro" /> Montenegro <option value="Netherlands" /> Netherlands <option value="Norway" /> Norway <option value="Poland" /> Poland <option value="Portugal" /> Portugal <option value="Romania" /> Romania <option value="San Marino" /> San Marino <option value="Serbia" /> Serbia <option value="Slovakia" /> Slovakia <option value="Slovenia" /> Slovenia <option value="Spain" /> Spain <option value="Sweden" /> Sweden <option value="Switzerland" /> Switzerland <option value="Ukraine" /> Ukraine <option value="United Kingdom" /> United Kingdom <option value="Vatican City" /> Vatican City <optgroup label="Asia"></optgroup> <option value="Afghanistan" /> Afghanistan <option value="Bahrain" /> Bahrain <option value="Bangladesh" /> Bangladesh <option value="Bhutan" /> Bhutan <option value="Brunei Darussalam" /> Brunei Darussalam <option value="Myanmar" /> Myanmar <option value="Cambodia" /> Cambodia <option value="China" /> China <option value="East Timor" /> East Timor <option value="Hong Kong" /> Hong Kong <option value="India" /> India <option value="Indonesia" /> Indonesia <option value="Iran" /> Iran <option value="Iraq" /> Iraq <option value="Israel" /> Israel <option value="Japan" /> Japan <option value="Jordan" /> Jordan <option value="Kazakhstan" /> Kazakhstan <option value="North Korea" /> North Korea <option value="South Korea" /> South Korea <option value="Kuwait" /> Kuwait <option value="Kyrgyzstan" /> Kyrgyzstan <option value="Laos" /> Laos <option value="Lebanon" /> Lebanon <option value="Malaysia" /> Malaysia <option value="Maldives" /> Maldives <option value="Mongolia" /> Mongolia <option value="Nepal" /> Nepal <option value="Oman" /> Oman <option value="Pakistan" /> Pakistan <option value="Palestine" /> Palestine <option value="Philippines" /> Philippines <option value="Qatar" /> Qatar <option value="Russia" /> Russia <option value="Saudi Arabia" /> Saudi Arabia <option value="Singapore" /> Singapore <option value="Sri Lanka" /> Sri Lanka <option value="Syria" /> Syria <option value="Taiwan" /> Taiwan <option value="Tajikistan" /> Tajikistan <option value="Thailand" /> Thailand <option value="Turkey" /> Turkey <option value="Turkmenistan" /> Turkmenistan <option value="United Arab Emirates" /> United Arab Emirates <option value="Uzbekistan" /> Uzbekistan <option value="Vietnam" /> Vietnam <option value="Yemen" /> Yemen <optgroup label="Oceania"></optgroup> <option value="Australia" /> Australia <option value="Fiji" /> Fiji <option value="Kiribati" /> Kiribati <option value="Marshall Islands" /> Marshall Islands <option value="Micronesia" /> Micronesia <option value="Nauru" /> Nauru <option value="New Zealand" /> New Zealand <option value="Palau" /> Palau <option value="Papua New Guinea" /> Papua New Guinea <option value="Samoa" /> Samoa <option value="Solomon Islands" /> Solomon Islands <option value="Tonga" /> Tonga <option value="Tuvalu" /> Tuvalu <option value="Vanuatu" /> Vanuatu <optgroup label="Africa"></optgroup> <option value="Algeria" /> Algeria <option value="Angola" /> Angola <option value="Benin" /> Benin <option value="Botswana" /> Botswana <option value="Burkina Faso" /> Burkina Faso <option value="Burundi" /> Burundi <option value="Cameroon" /> Cameroon <option value="Cape Verde" /> Cape Verde <option value="Central African Republic" /> Central African Republic <option value="Chad" /> Chad <option value="Comoros" /> Comoros <option value="Democratic Republic of the Congo" /> Democratic Republic of the Congo <option value="Republic of the Congo" /> Republic of the Congo <option value="Djibouti" /> Djibouti <option value="Egypt" /> Egypt <option value="Equatorial Guinea" /> Equatorial Guinea <option value="Eritrea" /> Eritrea <option value="Ethiopia" /> Ethiopia <option value="Gabon" /> Gabon <option value="Gambia" /> Gambia <option value="Ghana" /> Ghana <option value="Gibraltar" /> Gibraltar <option value="Guinea" /> Guinea <option value="Guinea-Bissau" /> Guinea-Bissau <option value="Cote d'Ivoire" /> Cote d'Ivoire <option value="Kenya" /> Kenya <option value="Lesotho" /> Lesotho <option value="Liberia" /> Liberia <option value="Libya" /> Libya <option value="Madagascar" /> Madagascar <option value="Malawi" /> Malawi <option value="Mali" /> Mali <option value="Mauritania" /> Mauritania <option value="Mauritius" /> Mauritius <option value="Morocco" /> Morocco <option value="Mozambique" /> Mozambique <option value="Namibia" /> Namibia <option value="Niger" /> Niger <option value="Nigeria" /> Nigeria <option value="Rwanda" /> Rwanda <option value="Sao Tome and Principe" /> Sao Tome and Principe <option value="Senegal" /> Senegal <option value="Seychelles" /> Seychelles <option value="Sierra Leone" /> Sierra Leone <option value="Somalia" /> Somalia <option value="South Africa" /> South Africa <option value="Sudan" /> Sudan <option value="Swaziland" /> Swaziland <option value="United Republic of Tanzania" /> United Republic of Tanzania <option value="Togo" /> Togo <option value="Tunisia" /> Tunisia <option value="Uganda" /> Uganda <option value="Zambia" /> Zambia <option value="Zimbabwe" /> Zimbabwe </select>
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" >Country</span>
</td>
</tr>
</tbody></table>
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);"></div>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_3" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>Email</b></span> <span style="color:red;"><small>*</small></span>
</td>
</tr>
<tr>
<td id="td_element_field_3" style="">
<input id="element_3" name="element_3" class="validate[required,custom[email]]" value="" size="30" type="text" />
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);"></div>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_4" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>Phone Number</b></span>
</td>
</tr>
<tr>
<td id="td_element_field_4" style="">
<input id="element_4" name="element_4" class="validate[optional,custom[telephone]]" value="" size="30" type="text" />
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);"></div>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_5" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>Items Ordered</b></span> <span style="color:red;"><small>*</small></span>
</td>
</tr>
<tr>
<td id="td_element_field_5" style="">
<textarea id="element_5" name="element_5" cols="100" rows="15" class="validate[required]"><br></textarea>
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);">
<small><span style="font-family:Verdana;">Include quantity next to item seperated by a comma. (i.e. item, 1)</span></small>
</div>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_6" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>Payment</b></span>
</td>
</tr>
<tr>
<td id="td_element_field_6" style="">
<select id="element_6" name="element_6" class="validate[optional]"> <option value="BCA" selected /> BCA <option value="MANDIRI" /> MANDIRI <option value="BNI" /> BNI </select>
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);"></div>
</td>
</tr>
<tr valign="top">
<td id="td_element_label_7" style="" align="">
<span style="color: rgb(0, 0, 0);font-family:Verdana;font-size:85%;" ><b>Comments and Questions</b></span>
</td>
</tr>
<tr>
<td id="td_element_field_7" style="">
<textarea id="element_7" name="element_7" cols="45" rows="5" class="validate[optional]"><br></textarea>
<div style="padding-bottom: 8px; color: rgb(0, 0, 0);"></div>
</td>
</tr>
<tr>
<td colspan="2" align="left">
<input name="element_counts" value="8" type="hidden" /> <input name="embed" value="forms" type="hidden" /><input value="Submit" type="submit" />
</td>
</tr>
</tbody></table>
</form>
<div>
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Selamat Datang di Kosmetikgue ^^,disini kami menjual aneka skin care dari korea,dengan harga jauh lebih murah dari dicounter-counter mall yang anda temui dan Dijamin Asli,karena kami mengimpornya langsung 100% distributor dikorea.
Diantara nya The Face shop, Etude, The skin Food, Missha , Bavipat,and more...
Untuk Order silakan mengirimkan SMS ke : 0852-1333-3083 / email : kosmetikgue@gmail.com
Dengan Format Sbb :
Nama :
ALamat Lengkap :
Pesanan : Nama Brands + Nama Product + brp pcs
Via Bank : BCA / Mandiri / BNI
Kami akan mengirimkan perinciannya max 1x24jam, harap dapat ditunggu ya.
Pembayaran yang sudah ditransfer bisa langsung diinfo melalui sms / hp dengan format :
Nama :
Lokasi : (ditakutkan adanya persamaan nama pesanan,utk membedakannya,kamu butuh lokasi anda. cth Jenny Surabaya)
Jumlah :
Nominal :
