Name of the person completing this form. *

First Name

Last Name

Phone number of the person completing this form. *

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What is the delivery address? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is the name of consignee (person receiving the shipment)? *

First Name

Last Name

What is the phone number of consignee (person receiving the shipment)? *

(###)

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