This form is pre-requisit for third party delivery. It is done because the address appeared in the shipment address is different from the one shown in the billing address. Or, you desire to present / deliver the order to your relative/ friend/ family.

Print this page and fill in all the necessary details Fax it to + 9221 - 5831176

OR

Print this page and fill in all the necessary details Scan it and e-mail it at orders@mystiqueasia.net

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 :	________________________________	front             back
Street Address :	________________________________
	________________________________
City :	________________________________
Province / State :	________________________________
Country :	________________________________
Telephone / Cell :	________________________________
Fax (optional) :	________________________________
Kindly, have my order delivered to the above address. Thankyou.
Name :	________________________________
Signature :	________________________________
Dated :	________________________________

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