PAYEE DETAILS ( PERSON WHO WILL BE PAYING TO CHAWLA MEDICOS)

NAME :
HOUSE NO. :
STREET :
COUNTRY :
CITY :
ZIPCODE :
MOBILE :
EMAIL ID. :

SHIPPING DETAILS ( PERSON TO WHOME PARCEL WILL BE SHIPPED)

NAME :
HOUSE NO. :
STREET :
COUNTRY :
CITY :
ZIPCODE :
MOBILE :
EMAIL ID. :
PRODUCT NAME & QUANTITY :