Name
*
First Name
Last Name
Email
*
example@example.com
Pernum ID
*
Referred by Pernum ID
Select Your Package
*
1,000 USD worth
5,000 USD with 10% extra value (5,500 USD)
10,000 USD with 20% extra value (12,000 USD)
25,000 USD with 50% extra value (37,500 USD)
Choose Your Payment Method
*
Bank Transfer
Bitcoin (BTC)
Ethereum (ETH)
Credit Card through Stripe
Charge my USD/EUR balance in my Pernum wallet
Pay 50% With YEM or LIQ
*
Yes, with YEM
Yes, with LIQ
No
BTC TXID - If you have paid using Bitcoin, kindly enter your TXID here.
Please send the BTC to wallet: bc1q07vsr623k9afnrlm46we3xhpnap9aju0vcmyj4
ETH TXID - If you have paid using Ethereum, kindly enter your TXID here.
Please send the ETH to wallet: 0xf8f5238E75e05D85c537b7ea12204d4679a178B2
Card Payment
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next
( X )
USD
Please enter net sum to pay not including YEM is used
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Signature - I hereby confirm having been informed all all terms included in the attached PDF.
*
FINISH AND SEND
Should be Empty: