Exclusive Provincial Distributor Payment Form

Exclusive City Distributor Payment Form
Invoice/Order No*
Full Name*

First NameLast Name
Facebook Name*
Contact Number*
E-mail*
example@example.com
Complete Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Province for Distribution:*
Amount:*
PAYMENT REFERENCE NUMBER/CODE*
Enter your reference located on your proof of payment.
Payment For:*

OrdersDistributorship
Terms:*

FullPartial/DP
MODES OF PAYMENT

YOUR PROOF OF PAYMENTS MUST BE SENT ONLY TO OUR REGISTERED ACCOUNT DETAILS BELOW:

BDO Unibank:

Account Name: JAY DE ROSALES
Account number: 0028 2028 4406

Bank of the Philippine Islands:

Account Name: JAY DE ROSALES
Account number: 0129 4722 14

Unionbank:

Account Name: JAY DE ROSALES VENTURES CORPORATION
Account number: 002610027479
Upload Proof of Payment*

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Notes
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Exclusive City Distributor Payment Form