FULL NAME *

Phone Number *

ALTERNATIVE PHONE Number

Region/Address

Quantity *--SELECT--PACKAGE--BUY ONE EYE REMEDY TEA: 250 CEDIS ONLYBUY TWO EYE REMEDY TEA: 450 CEDIS ONLY (RECOMMENDED)BUY THREE EYE REMEDY TEA: 650 CEDIS ONLYBUY FOUR EYE REMEDY TEA: 900 CEDIS ONLY (High Recommended)BUY FIVE EYE EYE REMEDY TEA: 1,100 CEDIS ONLY (Highly Recommended)

Customers' Consent *

• Yes, I Agree
• No, I Don't Consent

I agree that I am Intentionally Placing this order and that I am Financially ready and available to Receive my order as soon as it is brought to me.

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