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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 (若與上面地址不同):

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* 6. 品項編號:

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* 7. 品項名稱:

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* 8. 數量:

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* 9. 促銷代碼:

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* 10. 出貨選項:

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* 11. 總金額:

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* 12. 付款方式:

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