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advanced bankwire?

Bavarian Red

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I need a bankwire module that:
after selecting bankwire payment beside showing the information, it have 5 field for bank name, wire number, date of paying, description, attachment (for upload picture of bankwire) for customer to fill them and finish payment
save these info on the backoffice or directly send these info to moderator email (or any)

can i find it or any body make it?

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