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All that's needed for this form, is the product description to go in the text box as the name. All product and quantity is picked up by the script. Each product is entered onto a new line in Mal's, with the total including discount applied.
The prices are in this example: up to 6 - 13.95, up to 12 - 12.95, up to 24 - 11.95, up to 48 - 10.95.