濕疹按效支付 Eczema Pay-For-Success Application Form
Enrolment is on a first-come-first-served basis. 
名額有限,先到先得,額滿即止。

報名人需承擔至所在地之快遞及當地進口關稅
Applicants have to bear the courier fee and customs tax if applicable.

The Company reserves the right to make the final decision on the offer and any disputes, and may change the terms and conditions of this offer without prior notice. 
本公司保留對活動及任何爭議之最終決定權,並可更改此優惠之條款及細則而不作另行通知。
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First Name 名字 *
Surname 姓氏 *
Date of Birth 出生日期
*
MM
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DD
/
YYYY
Contact number 聯絡電話
*
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