EQUMED SDN BHD (1058591-T) EQUMED SDN BHD (1058591-T)

CUSTOMER’S DETAIL FORM CUSTOMER’S DETAIL FORM

Name : Name :
Address : Address :

No.Tel : No.Tel :
Date : Date :

NO ITEM DESCRIPTION QTY PRICE REMARKS NO ITEM DESCRIPTION QTY PRICE REMARKS

TERMS OF PAYMENT: CASH / DEBIT CARD / ONLINE TRANSFER TOTAL RM TERMS OF PAYMENT: CASH / DEBIT CARD / ONLINE TRANSFER TOTAL RM

Thank You and Best Regard Prepared By Thank You and Best Regard Prepared By

Name: Name:
EQ/CDF/REV01 EQ/CDF/REV01