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公司名稱 Company name *

負責人 Representative name *

送貨地址（建築物名稱）Delivery address (Building name) *

送貨地址（地址）Delivery address (Address) *

送貨地址（城市) Delivery address (District) *

送貨地址（區）Delivery address (City) *

統一編號 Tax number *

電子信箱 Email address *

Line ID *