tag:blogger.com,1999:blog-83219105826044492752011-04-21T10:58:33.086-07:00kawaii.lens@gmail.comhttp://www.blogger.com/profile/11792331032412925295noreply@blogger.comBlogger11100tag:blogger.com,1999:blog-8321910582604449275.post-31567361831577107082008-09-29T21:08:00.000-07:002008-10-11T20:06:22.918-07:00<!-- Begin Freedback Form --><br /><!-- DO NOT EDIT YOUR FORM HERE, PLEASE LOG IN AND EDIT AT FREEDBACK.COM --><br /><form enctype="multipart/form-data" method="post" action="http://www.freedback.com/mail.php" accept-charset="UTF-8"><br /> <div><br /> <input type="hidden" name="acctid" id="acctid" value="9mnwk1cy7iyo0be6" /><br /> <input type="hidden" name="formid" id="formid" value="480590" /><br /> <input type="hidden" name="required_vars" id="required_vars" value="name,field-1725ea2940b4bc4,field-86ea8c22fe569ed,email,field-5da13b106829735,field-8492e46759426e7,field-c200b9cf667d869,field-6ad5b4d34a35055,field-2b4d4874637c65f" /><br /> </div><br /> <table cellspacing="5" cellpadding="5" border="0"><br /> <tr><br /> <td valign="top"><br /> <strong>Name:</strong><br /> </td><br /> <td valign="top"><br /> <input type="text" name="name" id="name" size="40" value="" /><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Address:</strong><br /> </td><br /> <td valign="top"><br /> <textarea name="field-1725ea2940b4bc4" id="field-1725ea2940b4bc4" rows="6" cols="40"></textarea><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Contact Number:</strong><br /> </td><br /> <td valign="top"><br /> <input type="text" name="field-86ea8c22fe569ed" id="field-86ea8c22fe569ed" size="40" value="" /><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Email Address:</strong><br /> </td><br /> <td valign="top"><br /> <input type="text" name="email" id="email" size="40" value="" /><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Product name/code:</strong><br /> </td><br /> <td valign="top"><br /> <select name="field-5da13b106829735" id="field-5da13b106829735"><br /> <option value="GEO Angel, Purple, CM831">GEO Angel, Purple, CM831</option><br /> <option value="GEO Angel, Blue, CM832">GEO Angel, Blue, CM832</option><br /> <option value="GEO Angel, Green, CM833">GEO Angel, Green, CM833</option><br /> <option value="GEO Angel, Brown, CM834">GEO Angel, Brown, CM834</option><br /> <option value="GEO Angel, Grey, CM835">GEO Angel, Grey, CM835</option><br /> <option value="GEO Nudy Quarter, Purple, CH621">GEO Nudy Quarter, Purple, CH621</option><br /> <option value="GEO Nudy Quarter, Blue, CH622">GEO Nudy Quarter, Blue, CH622</option><br /> <option value="GEO Nudy Quarter, Green, CH623">GEO Nudy Quarter, Green, CH623</option><br /> <option value="GEO Nudy Quarter, Brown, CH624">GEO Nudy Quarter, Brown, CH624</option><br /> <option value="GEO Nudy Quarter, Grey, CH625">GEO Nudy Quarter, Grey, CH625</option><br /> <option value="GEO Nudy Quarter, Aqua, CH626/935">GEO Nudy Quarter, Aqua, CH626/935</option><br /> <option value="Honey Wing, Brown, TS104">Honey Wing, Brown, TS104</option><br /> <option value="Honey Wing, Grey, TS105">Honey Wing, Grey, TS105</option><br /> <option value="Fresh Colour, Brown">Fresh Colour, Brown</option><br /> <option value="Fresh Colour, Grey">Fresh Colour, Grey</option><br /> <option value="Tear Lens, Brown">Tear Lens, Brown</option><br /> <option value="Tear Lens, Grey">Tear Lens, Grey</option><br /> <option value="TWO TONE, Purple, CM721">TWO TONE, Purple, CM721</option><br /> <option value="TWO TONE, Blue, CM722">TWO TONE, Blue, CM722</option><br /> <option value="TWO TONE, Green, CM723">TWO TONE, Green, CM723</option><br /> <option value="TWO TONE, Brown, CM724">TWO TONE, Brown, CM724</option><br /> <option value="TWO TONE, Grey, CM725">TWO TONE, Grey, CM725</option><br /> <option value="TRI TONE, Grey, CM901">TRI TONE, Grey, CM901</option><br /> <option value="TRI TONE, Brown, CM902">TRI TONE, Brown, CM902</option><br /> <option value="TRI TONE, Green, CM903">TRI TONE, Green, CM903</option><br /> <option value="TRI TONE, Blue, CM904">TRI TONE, Blue, CM904</option><br /> <option value="TRI TONE, Purple, CM905">TRI TONE, Purple, CM905</option><br /> <option value="Melon">Melon</option><br /> <option value="IM 101">IM 101</option><br /> <option value="IM 102">IM 102</option><br /> <option value="IM 107">IM 107</option><br /> <option value="IM 108">IM 108</option><br /> <option value="IM 114">IM 114</option><br /> <option value="CK 101">CK 101</option><br /> <option value="CK 105">CK 105</option><br /> <option value="CK 107">CK 107</option><br /> <option value="ANGEL 101, Black">ANGEL 101, Black</option><br /> <option value="CM 836">CM 836</option><br /> <option value="JB 101">JB 101</option><br /> <option value="JB 102">JB 102</option><br /> </select><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Right eye Degree:</strong><br /> </td><br /> <td valign="top"><br /> <select name="field-8492e46759426e7" id="field-8492e46759426e7"><br /> <option value="0, -0.00">0, -0.00</option><br /> <option value="25, -0.25">25, -0.25</option><br /> <option value="50, -0.50">50, -0.50</option><br /> <option value="75, -0.75">75, -0.75</option><br /> <option value="100, -1.00">100, -1.00</option><br /> <option value="125, -1.25">125, -1.25</option><br /> <option value="150, -1.50">150, -1.50</option><br /> <option value="175, -1.75">175, -1.75</option><br /> <option value="200, -2.00">200, -2.00</option><br /> <option value="225, -2.25">225, -2.25</option><br /> <option value="250, -2.50">250, -2.50</option><br /> <option value="275, -2.75">275, -2.75</option><br /> <option value="300, -3.00">300, -3.00</option><br /> <option value="325, -3.25">325, -3.25</option><br /> <option value="350, -3.50">350, -3.50</option><br /> <option value="375, -3.75">375, -3.75</option><br /> <option value="400, -4.00">400, -4.00</option><br /> <option value="425, -4.25">425, -4.25</option><br /> <option value="450, -4.50">450, -4.50</option><br /> <option value="475, -4.75">475, -4.75</option><br /> <option value="500, -5.00">500, -5.00</option><br /> <option value="550, -5.50">550, -5.50</option><br /> <option value="600, -6.00">600, -6.00</option><br /> <option value="650, -6.50">650, -6.50</option><br /> <option value="700, -7.00">700, -7.00</option><br /> <option value="750, -7.50">750, -7.50</option><br /> <option value="800, -8.00">800, -8.00</option><br /> <option value="850, -8.50">850, -8.50</option><br /> <option value="900, -9.00">900, -9.00</option><br /> <option value="950, -9.50">950, -9.50</option><br /> <option value="1000, -10.00">1000, -10.00</option><br /> </select><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Left eye Degree:</strong><br /> </td><br /> <td valign="top"><br /> <select name="field-c200b9cf667d869" id="field-c200b9cf667d869"><br /> <option value="0, -0.00">0, -0.00</option><br /> <option value="25, -0.25">25, -0.25</option><br /> <option value="50, -0.50">50, -0.50</option><br /> <option value="75, -0.75">75, -0.75</option><br /> <option value="100, -1.00">100, -1.00</option><br /> <option value="125, -1.25">125, -1.25</option><br /> <option value="150, -1.50">150, -1.50</option><br /> <option value="175, -1.75">175, -1.75</option><br /> <option value="200, -2.00">200, -2.00</option><br /> <option value="225, -2.25">225, -2.25</option><br /> <option value="250, -2.50">250, -2.50</option><br /> <option value="275, -2.75">275, -2.75</option><br /> <option value="300, -3.00">300, -3.00</option><br /> <option value="325, -3.25">325, -3.25</option><br /> <option value="350, -3.50">350, -3.50</option><br /> <option value="375, -3.75">375, -3.75</option><br /> <option value="400, -4.00">400, -4.00</option><br /> <option value="425, -4.25">425, -4.25</option><br /> <option value="450, -4.50">450, -4.50</option><br /> <option value="475, -4.75">475, -4.75</option><br /> <option value="500, -5.00">500, -5.00</option><br /> <option value="550, -5.50">550, -5.50</option><br /> <option value="600, -6.00">600, -6.00</option><br /> <option value="650, -6.50">650, -6.50</option><br /> <option value="700, -7.00">700, -7.00</option><br /> <option value="750, -7.50">750, -7.50</option><br /> <option value="800, -8.00">800, -8.00</option><br /> <option value="850, -8.50">850, -8.50</option><br /> <option value="900, -9.00">900, -9.00</option><br /> <option value="950, -9.50">950, -9.50</option><br /> <option value="1000, -10.00">1000, -10.00</option><br /> </select><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Method of Payment:</strong><br /> </td><br /> <td valign="top"><br /> <input type="checkbox" name="field-6ad5b4d34a35055[]" id="field-6ad5b4d34a35055_0" value="Bank transfer [within Australia only]" /> Bank transfer [within Australia only]<br/><br /> <input type="checkbox" name="field-6ad5b4d34a35055[]" id="field-6ad5b4d34a35055_1" value="PAYPAL" /> PAYPAL<br/><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Where did you hear about us?<br /> If from another website, please list.<br /> Thank you!</strong><br /> </td><br /> <td valign="top"><br /> <textarea name="field-2b4d4874637c65f" id="field-2b4d4874637c65f" rows="6" cols="40"></textarea><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td valign="top"><br /> <strong>Any other types/brand of lens you would like us to bring in? </strong><br /> </td><br /> <td valign="top"><br /> <textarea name="field-d62cf23baa1c7c2" id="field-d62cf23baa1c7c2" rows="6" cols="40"></textarea><br /> <br /> </td><br /> </tr><br /> <tr><br /> <td colspan="2" align="center"><br /> <input type="submit" value=" Submit Form " /><br /> </td><br /> </tr><br /> </table><br /></form><br /><br><center><font face="Arial, Helvetica" size="1"><b><br /><a href="http://www.kawaii-lens.blogspot.com">HOME</a><br /></b></font></center><br /><!-- End Freedback Form --><div class="blogger-post-footer"><img width='1' height='1' src='https://blogger.googleusercontent.com/tracker/8321910582604449275-3156736183157710708?l=kawaii-lens-orderform.blogspot.com' alt='' /></div>kawaii.lens@gmail.comhttp://www.blogger.com/profile/11792331032412925295noreply@blogger.com0