Direct Debit Form

Search

Direct Credit Order Form

Please complete the form below with your order and deposit money into the account below within 1 day of submitting your order.
As soon as payment is cited your order will be dispatched for shipping.

Bank Details are as follows:
Account Name: Immersion Cosmetics
Account Number: 06-0821-0556559-00

YOUR DETAILS

SHIPPING INFORMATION

* Indicates required field

First Name *

Last Name *

Email *

Phone Number *

Street Address *

Suburb *

City *

Post Code *

ORDER

Please complete the below with the product information you would like to order.

Product Name *

Colour / Shade *

Price *

Product Name *

Colour / Shade *

Price *

Product Name *

Colour / Shade *

Price *

Product Name *

Colour / Shade *

Price *

Product Name *

Colour / Shade *

Price *

NZ FLAT RATE SHIPPING.
AUSTRALIA POST SHIPPING.

$8.00
$17.00

ORDER TOTAL: *

Submit