Life Mates Payment Form
Member #
*
Sponsor Name
First Name
Last Name
Sponsor ID
JP
# 5 Digits
Member Name
*
First Name
Last Name
Today’s Date
-
Month
-
Day
Year
Member Email
*
example@example.com
Paid Amount
*
Introduction Fee
*
Match Maker Name
*
Match Maker ID #
*
Initials
5 Digit Number
Member Phone Number
*
Sex
*
Male
Female
Membership Options
prev
next
( X )
Choosing Plan
(
¥150,000
¥
150,000
one-time payment)
(A) Platinum Choosing 1 Year Introduction Fee 4,000円
Choosing Plan
(
¥100,000
¥
100,000
one-time payment)
(B) Gold Choosing 6 Months Introduction Fee 5,000円
Members Choose You
(
¥80,000
¥
80,000
one-time payment)
(C) Platinum Choose Me 1 Year Introduction Fee 4,000円
Members Choose You
(
¥40,000
¥
40,000
one-time payment)
(D) Gold Choose Me 6 Months / Introduction Fee 5,000円
------------------------------------------------------------
(
Free
¥
Free
for each
day
)
Upgrade / Add Fees / Campaign /
(
¥30,000
¥
30,000
one-time payment)
(E) Plan Discount / Upgrade
Upgrade / Add Fees / Campaign /
(
¥20,000
¥
20,000
one-time payment)
(F) Plan Discount / Upgrade
Upgrade / Add Fees / Campaign /
(
¥10,000
¥
10,000
one-time payment)
(G) Plan Discount / Upgrade
Free Service Plan Campaign
(
Free
¥
Free
for each
day
)
Membership Plans / Upgrades / Discounts / Campaigns
1
2
3
4
5
Submit
Should be Empty: