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<form enctype="multipart/form-data" method="post" action="
http://www.freedback.com/mail.php" accept-charset="UTF-8">
<div>
<input type="hidden" name="acctid" id="acctid" value="yhhaxmylsi8j90sy" />
<input type="hidden" name="formid" id="formid" value="316463" />
<input type="hidden" name="required_vars" id="required_vars" value="name,field-b7dfc70d16256d1,email,field-c7dc924c2fc4cde,field-c1034ea82594409" />
</div>
<table cellspacing="5" cellpadding="5" border="0">
<tr>
<td valign="top">
<strong>Name:</strong>
</td>
<td valign="top">
<input type="text" name="name" id="name" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Landline/ Cellphone:</strong>
</td>
<td valign="top">
<input type="text" name="field-b7dfc70d16256d1" id="field-b7dfc70d16256d1" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Email Address:</strong>
</td>
<td valign="top">
<input type="text" name="email" id="email" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Website/ Multiply (if any):</strong>
</td>
<td valign="top">
<input type="text" name="field-5a5650f77109ed4" id="field-5a5650f77109ed4" size="40" value="" />
</td>
</tr>
<tr>
<td valign="top">
<strong>Mode of Payment (Required):</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-c7dc924c2fc4cde[]" id="field-c7dc924c2fc4cde_0" value="Landbank deposit" /> Landbank deposit<br/>
<input type="checkbox" name="field-c7dc924c2fc4cde[]" id="field-c7dc924c2fc4cde_1" value="G-cash (Add Php10 to the total amount)" /> G-cash (Add Php10 to the total amount)<br/>
<input type="checkbox" name="field-c7dc924c2fc4cde[]" id="field-c7dc924c2fc4cde_2" value="Western Union (for international buyers" /> Western Union (for international buyers<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Complete Shipping Address:</strong>
</td>
<td valign="top">
<textarea name="field-c1034ea82594409" id="field-c1034ea82594409" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Item Name and quantity (Please specify color and size):</strong>
</td>
<td valign="top">
<textarea name="field-2d0268ebfef8e35" id="field-2d0268ebfef8e35" rows="6" cols="40"></textarea>
</td>
</tr>
<tr>
<td valign="top">
<strong>Delivery charge/ Location:</strong>
</td>
<td valign="top">
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_0" value="PROMO #1: FREE DELIVERY WITHIN M.MANILA FOR 2 ITEMS OR MORE" /> PROMO #1: FREE DELIVERY WITHIN M.MANILA FOR 2 ITEMS OR MORE<br/>
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_1" value="PROMO #2: FREE DELIVERY FOR PROVINCIAL AREAS FOR 3 ITEMS OR MORE" /> PROMO #2: FREE DELIVERY FOR PROVINCIAL AREAS FOR 3 ITEMS OR MORE<br/>
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_2" value="Php 50 half kilo within Metro Manila via XEND Express" /> Php 50 half kilo within Metro Manila via XEND Express<br/>
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_3" value="Php 100 half kilo Provincial areas via XEND" /> Php 100 half kilo Provincial areas via XEND<br/>
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_4" value="Php 80 half kilo within Metro Manila via Air21" /> Php 80 half kilo within Metro Manila via Air21<br/>
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_5" value="Php 95 one kilo within Metro Manila via Air21" /> Php 95 one kilo within Metro Manila via Air21<br/>
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_6" value="Php 120 outside Metro Manila via Air21" /> Php 120 outside Metro Manila via Air21<br/>
<input type="radio" name="field-0bded590503cbfd" id="field-0bded590503cbfd_7" value="International address. Via FEDEX or XEND Express. Rates will be mailed to you." /> International address. Via FEDEX or XEND Express. Rates will be mailed to you.<br/>
</td>
</tr>
<tr>
<td valign="top">
<strong>Terms and Conditions:</strong>
</td>
<td valign="top">
<input type="checkbox" name="field-4fd659f1dd10831[]" id="field-4fd659f1dd10831_0" value="I agree that there is an additional delivery charge to my purchase/s." /> I agree that there is an additional delivery charge to my purchase/s.<br/>
<input type="checkbox" name="field-4fd659f1dd10831[]" id="field-4fd659f1dd10831_1" value="I agree that I have 3 days to settle payment for my order/s unless otherwise agreed upon." /> I agree that I have 3 days to settle payment for my order/s unless otherwise agreed upon.<br/>
<input type="checkbox" name="field-4fd659f1dd10831[]" id="field-4fd659f1dd10831_2" value="I agree that I have read, understood and accepted My Pink Closet's Policy." /> I agree that I have read, understood and accepted My Pink Closet's Policy.<br/>
</td>
</tr>
<tr>
<td colspan="2" align="center">
<input type="submit" value=" Submit Form " />
</td>
</tr>
</table>
</form>
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