Registration Form

1.2 ORDER FORM

Please complete the following Order details:
Membership Package*

Silver-P8,880Gold-P10,888Platinum-P15,888
Additional Order
Payment Method*
2.2 REGISTRATION DETAILS

To become an authorized dealer or registered member of JC Premiere, we need to register your selected Order Package under your name. Please complete the following registration details:
Full Name*

First NameLast Name
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Number*
Birthdate*
Dependent's Name*

First NameLast Name
Dependents Age
Relationship*
Do you have a sponsor?

YesNo
Should be Empty: