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By John - Formulir Daftar Oriflame
Questions marked by * are required.
1.	Name: *
2.	Email: *
3.	Tanggal Lahir (tgl-Bulan-Tahun)
4.	No KTP / SIM: *
5.	Telepon:
6.	Handphone(Hp):
7.	Alamat Tempat Tinggal: *
8.	RT/RW
9.	Kota:
10.	Kode Pos: