Order Form

Customer Information			Shipping Details (if different)

Name			Name
Address			Address
City			City
Country			Country
Zip			Zip
Phone			Phone
Fax			Fax
Email			Email

Product Orders

Item#	Qty	Description	Size	Price	Total


















			TOTAL

Method of Payment

Type of payment :	Check
	Money Order
	Wire Transfer
	Others (please specify)

Details :

(e.g. check no)

Additional Information

Ordered by,

Indoshell
Ruko Glodok Jaya No 75 - 76, Jl. Hayam Wuruk, Jakarta 11180 - Indonesia
Phone : +62 21 625 5541, Fax: + 62 21 626 3784, Email : shell@indoshell.com