, 2002  
 
Remittance Form
Required fields are indicated by an asterisk (*).
 1. Payee Information
Title  
First Name *
Middle Name  
Last Name *
Birth Date      
Address Line 1 *
Address Line 2  
City *     Zip Code  
Province *
Country Philippines
Phone Number 1 *
Phone Number 2  
Fax Number  
E-Mail Address 1  
E-Mail Address 2  
URL  
 
 2. Enter Amount

Dollar Amount to be Sent: *

 PESO Equivalent:
(Amount to be deducted from your account)
 3. Destination & Delivery Options

Choose Destination:

Delivery Fee:  

Choose Delivery Options

 

 
 

 


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