END USER PRODUCT/SERVICE ORDER FORM 1. BASIC INFORMATION NAME (required) ADDRESS (required) CITY (required) TOWN (required) STATE (required) TELEPHONES NOS: (required) EMAIL (required) 2. ITEMS ORDERED A. PRODUCT/SERVICE DESCRIPTION (PLEASE SELECT FROM LIST) (required) —Please choose an option—AntiXplosion KEG 10LitreAntiXplosion KEG 25LitreAntixplosion Gas CylinderFamily Fire GloveFamily Fire BlanketFire Extinguisher BallFire Safety BootFire Safety HelmetFire Resistant JacketAmebo WirelessRetrofit Gas CylinderGas Cylinder ProRetrofit AutomobilesArmoured TankArmoured GeneratorsForensic Fire Investigation Quantity (required) Delivery Time (in days) e.g 3 days (required) Referral Code [For End Users referred by another User] B. PRODUCT/SERVICE DESCRIPTION (PLEASE SELECT FROM LIST) —Please choose an option—Antixplosion KegAntixplosion Gas CylinderFamily Fire GloveFamily Fire BlanketFire Extinguisher BallFire Safety BootFire Safety HelmetFire Resistant JacketAmebo WirelessRetrofit Gas CylinderGas Cylinder ProRetrofit AutomobilesArmoured TankArmoured GeneratorsForensic Fire Investigation Quantity Delivery Time (in days) e.g 3 days Referral Code (For End Users referred by another User) C. PRODUCT/SERVICE DESCRIPTION (PLEASE SELECT FROM LIST) —Please choose an option—Antixplosion KegAntixplosion Gas CylinderFamily Fire GloveFamily Fire BlanketFire Extinguisher BallFire Safety BootFire Safety HelmetFire Resistant JacketAmebo WirelessRetrofit Gas CylinderGas Cylinder ProRetrofit AutomobilesArmoured TankArmoured GeneratorsForensic Fire Investigation Quantity Delivery Time (in days) e.g 3 days Referral Code (For End Users referred by another User) 3. DELIVERY METHOD [note that delivery charges apply for delivery to Customer Address] (REQUIRED) —Please choose an option—Self PickupDelivery to Customer 3.1 If delivery is to Customer Address, please specify delivery address: Address City Town State 4. PAYMENT TYPE —Please choose an option—ChequeCashBank TransferePayment Note: Half completed or poorly completed forms cannot be processed
