BORANG PESANAN/ORDER FORM

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Pembayaran boleh dibuat melalui/The payment can be made by:

Dari Malaysia/From Malaysia:

(i) Tunai/Cash
(ii) Wang Pos/Postal Order
(iii) Cek/Cheque

Luar Negara/Overseas:
(iv) Bank Deraf/Bank Draft

*Bayaran hendaklah dibuat atas nama Institut Kesihatan Negara/
The Payment must be paid under the name of National Institutes of Health (NIH) Malaysia

Judul Penerbitan/Title of Publication: *

Salinan Pembelian/Copy of Purchase *

Nama Penuh/Full name: *

Nama Syarikat/Company Name:

Alamat Penuh/Full Address: *

Poskod/Post Code: *

Nombor Telefon/Phone Number: *

Nombor Faks/Fax Number:

E-mel/E-mail: *

Pesanan/Order *

Pesanan Individu/Individual Order

Pesanan Syarikat/Company Order

Sendiri Ambil/Self Pick Up/Kurier/Courier

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