tag:blogger.com,1999:blog-18968064248942830182011-07-07T16:26:26.422-07:00aphrodites-apparelshttp://www.blogger.com/profile/18000399631052030969noreply@blogger.comBlogger11100tag:blogger.com,1999:blog-1896806424894283018.post-81552524033495803452009-02-05T08:24:00.001-08:002009-02-22T05:48:57.897-08:00<form action="http://www.freedback.com/mail.php" method="post" enctype="multipart/form-data" charset="UTF-8"><p><br /><br /><input id="acctid" type="hidden" value="sty00ycamfpgc2d7" name="acctid"><br /><input id="formid" type="hidden" value="546581" name="formid"><br /><input id="required_vars" type="hidden" value="name,field-f5233d94cc2f8dd,email,field-fdaffc552e38784,field-5c8ecfb041bebc5,field-16b2b2455f4b90f,field-e48507c26935529,field-fdc7c9976cb8c3e" name="required_vars"><br /><br /><a href="http://aphrodites-apparels.blogspot.com/"><span style="font-size:130%;"><span style="color:#ff1493;">Click here to return to Aphrodite's Apparels' main page!</a></span></span> </p><p><br /><tr><td valign="top"><strong>Name:</strong> </p><p><input id="name" size="40" name="name"><br /></td></tr><tr><td valign="top"><br /><strong>Gender</strong><br /></td><td valign="top"><br /><input id="field-f5233d94cc2f8dd_0" type="radio" value="Male" name="field-f5233d94cc2f8dd"> Male<br /><input id="field-f5233d94cc2f8dd_1" type="radio" value="Female" name="field-f5233d94cc2f8dd"> Female<br /><input id="field-f5233d94cc2f8dd_2" type="radio" value="Prefer Not To Say" name="field-f5233d94cc2f8dd"> Prefer Not To Say<br /></td></tr><tr><td valign="top"><br /><strong>Age Group:</strong><br /></td><td valign="top"><br /><input id="field-83bac56e3ef3bba_0" type="radio" value="13&lt;" name="field-83bac56e3ef3bba"> 13><br /><input id="field-83bac56e3ef3bba_1" type="radio" value="13-16" name="field-83bac56e3ef3bba"> 13-16<br /><input id="field-83bac56e3ef3bba_2" type="radio" value="17-19" name="field-83bac56e3ef3bba"> 17-19<br /><input id="field-83bac56e3ef3bba_3" type="radio" value="21-25" name="field-83bac56e3ef3bba"> 20-25<br /><input id="field-83bac56e3ef3bba_4" type="radio" value="25-30" name="field-83bac56e3ef3bba"> 26-30<br /><input id="field-83bac56e3ef3bba_5" type="radio" value="30&lt;" name="field-83bac56e3ef3bba"> 30< <input id="field-83bac56e3ef3bba_5" type="radio" value="30&lt;" name="field-83bac56e3ef3bba"> Not Saying!<br /><br /></td></tr><tr><td valign="top"><strong>Contact Number</strong><br /></td><td valign="top"><br /><input id="field-addaf8c697ea936" size="40" name="field-addaf8c697ea936"><br /></td></tr><tr><td valign="top"><br /><strong>Email Address:</strong><br /></td><td valign="top"><br /><input id="email" size="40" name="email"><br /><br /></td></tr><tr><td valign="top"><strong>1st Item Name<br /></strong><br /></td><td valign="top"><input id="field-fdaffc552e38784" size="40" name="field-fdaffc552e38784"><br /><br /></td></tr><tr><td valign="top"><strong>Quantity, Colour, Size (if applicable)</strong><br /></td><br /><td valign="top"><input id="field-5c8ecfb041bebc5" size="40" name="field-5c8ecfb041bebc5"><br /><br /></td></tr><tr><td valign="top"><strong>Discount code (if applicable)</strong><br /></td><td valign="top"><br /><input id="field-6ff14af19685593" size="40" name="field-6ff14af19685593"><br /></td></tr><tr><td valign="top"><br /><strong>2nd Item name</strong><br /></td><td valign="top"><br /><input id="field-b728aa76ee9ab66" size="40" name="field-b728aa76ee9ab66"><br /><br /></td></tr><tr><td valign="top"><strong>Quantity, Colour, Size (if applicable)</strong><br /></td><br /><td valign="top"><input id="field-a7d31da18f9b9ec" size="40" name="field-a7d31da18f9b9ec"><br /></td></tr><tr><td valign="top"><br /><strong>Discount Code</strong><br /></td><td valign="top"><br /><input id="field-ef5abbabab4d292" size="40" name="field-ef5abbabab4d292"><br /><br /></td></tr><tr><td valign="top"><strong>Additional Items</strong><br /></td><br /><td valign="top"><textarea id="field-8e0d169a3b4eca9" name="field-8e0d169a3b4eca9" rows="6" cols="40"></textarea><br /><br /></td></tr><tr><td valign="top"><strong>Opt for registered mail? (extra $2)</strong><br /></td><br /><td valign="top"><input id="field-16b2b2455f4b90f_0" type="radio" value="Yes" name="field-16b2b2455f4b90f"> Yes<br /><input id="field-16b2b2455f4b90f_1" type="radio" value="No" name="field-16b2b2455f4b90f"> No<br /></td></tr><tr><td valign="top"><br /><strong>Mailing Address</strong><br /></td><td valign="top"><br /><textarea id="field-e48507c26935529" name="field-e48507c26935529" rows="6" cols="40">Address :<br />Singapore : </textarea><br /><br /></td></tr><tr><td valign="top"><strong>Payment Method:</strong><br /></td><br /><td valign="top"><input id="field-fdc7c9976cb8c3e_0" type="radio" value="ibanking" name="field-fdc7c9976cb8c3e"> ibanking<br /><input id="field-fdc7c9976cb8c3e_1" type="radio" value="atm transfer" name="field-fdc7c9976cb8c3e"> atm transfer<br /><input id="field-fdc7c9976cb8c3e_2" type="radio" value="concealed cash mail" name="field-fdc7c9976cb8c3e"> concealed cash mail<br /><input id="field-fdc7c9976cb8c3e_3" type="radio" value="meetup" name="field-fdc7c9976cb8c3e"> meetup<br /></td></tr><tr><td valign="top"><br /><strong>Referral's Full Name (if applicable)</strong><br /></td><br /><input id="field-2012a700db22353" size="40" name="field-2012a700db22353"><br /><br /></td></tr><tr><td valign="top"><strong>Fill up here if you have already paid for your product</strong><br /></td><br /><td valign="top"><textarea id="field-69da17a473126b1" name="field-69da17a473126b1" rows="6" cols="40">Ibanking nick :<br />Transaction reference :<br />Date of Transfer :<br />Amount Paid :</textarea><br /></td></tr><tr><td valign="top"><br /><strong>Please tell us how did you find out about AA/feedback/special request!</strong><br /></td><td valign="top"><br /><textarea id="field-870e3bd3763ef0d" name="field-870e3bd3763ef0d" rows="6" cols="40"></textarea><br /><br /></td></tr><tr><br /><td align="center" colspan="2"><br /><input type="submit" value=" Submit Form "><br /></td><br /></tr><br /></p></form><br /><br /><center><span style="font-family:Arial, Helvetica;font-size:78%;"><b><br /><br /><!-- End Freedback Form --><br /></b></span></center><div class="blogger-post-footer"><img width='1' height='1' src='https://blogger.googleusercontent.com/tracker/1896806424894283018-8155252403349580345?l=aphrodites-order-form.blogspot.com' alt='' /></div>aphrodites-apparelshttp://www.blogger.com/profile/18000399631052030969noreply@blogger.com35