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Courier Collection Request
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Collection from
Name & Surname:
*
Company Name/ Department:
*
Street address:
*
Suburb:
*
Town / City:
*
Telephone number:
*
Email:
*
Cell:
*
Contents: Description of Goods
Value:
*
Insurance:
*
Description of goods:
*
Deliver to
Postal Service
Other Address
Name & Surname:
*
Company name:
*
Department:
*
Street address:
*
Suburb:
*
Telephone number:
*
Cell:
*
Special handling instructions
Instructions:
*
Requester Details
Contact Name & Surname:
*
Extension:
Cost Centre:
*
Account Number:
*
Date:
Department: