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Please take a moment to fill up the following items.

1.  Full Name:

2.  Member's Personal Code:

3.  E-mail Address: (REQUIRED)

4.  Preffered Delivery Time (eg.2-3pm)

5.  Preffered Delivery Day (eg.weekdays)

6.  Preffered Grocery Store (eg.SM Supermarket, Tiong San)

7.  Special Instructions (eg. Don't change any Items)

8.  Order List
Quantity/Item & Product Brand/Descrition
(eg. 1 - Tang Pineapple - 250g)

9.  Contact number for confirmation: