confirm payment

sister,please write this form ....
thank you,
*WAJIB !!!!!!!!

Name
BANK TRANSFER NAME	BRI BNI MANDIRI BCA OTHER BANK/lainnya
WESTERN UNION (for international buyers)  write MTCN code
BANK ACCOUNT NAME nama pemilik rekening
BANK ACCOUNT NUMBER nomor rekening transfer
DATE OF PAYMENT example 6/9/2011
PAYMENT/pembayaran example 200.000

Form provided by Freedback.