| I
hereby authorize Mystique Asia inc. to deliver my
order on following information |
|
|
|
| Order
Number : |
________________________________ |
Attach
copy of your Driver's License or a photo identification
with signature for verification purpose |
| Recipient's
Name : |
________________________________ |
|
| Street
Address : |
________________________________ |
|
________________________________ |
| City
: |
________________________________ |
| Province
/ State : |
________________________________ |
| Country
: |
________________________________ |
| Telephone
/ Cell : |
________________________________ |
| Fax
(optional) : |
________________________________ |
|
|
| Kindly,
have my order delivered to the above address. Thankyou. |
|
| Name
: |
________________________________ |
|
|
| Signature
: |
________________________________ |
| Dated
: |
________________________________ |