ORDER FORM 

          To,
          Laxmi Lining Materials Pvt. Ltd;
          Sodal Road, Preet Nagar, P.O. Box No. 458.
          Jalandhar - 144004 (Pb.)
          Contact No. 0181 2990355, 2990760, Fax No. 0181 2295110
 

          Dear Sir,
          Please dispatch me nos. PROVITA4 Model PV1315 B Model PV1315F (Please tick one).
 

          Customer Details:
           Please ensure you give us a daytime phone no. & delivery address where there is someone to sign for the parcel
           against the production of Proof Of Identity. Please use BLOCK LETTERS.
 

          Mr. / Ms                                  Mr. / Ms      
                                                    
          Address1       Address1    

          Address2       Address2   

          City              PIN                                City         PIN

          State                                         State        

          Ph. No (R) (O)                         Ph. No (R) (O)

          Mobile No            

           E-mail