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* 1. 姓名:

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* 3. 電話:

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* 4. 寄送地址:

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* 5. 帳單地址 (若與寄送地址不同):

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* 6. 請描述購買品項:

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* 7. 請逐項列出金額:

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* 8. 總金額:

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* 9. 付款方式:

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* 10. 已付金額:

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