Customer Order Form
LEGAL WAVE DISTRIBUTION
Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Our Products
*
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( X )
OX EEZE 15 Capsule
$
200.00
Quantity
5
10
15
20
25
30
Item subtotal:
$
0.00
ZAZA RED
$
275.00
Quantity
5
10
15
20
25
30
35
Item subtotal:
$
0.00
TATA MAX 15 Capsule
$
200.00
Quantity
5
10
15
20
Item subtotal:
$
0.00
Total Amount
Delivery Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Special Delivery Instructions
Submit
Should be Empty: