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EURO PAY INC

Registration Form

Application No:

Personal Information Details: Euro I.D Date:

First Name Middle Name Last Name

Sex: Male Female Marital Status: Single Married

Date of Birth: Edu.Qualification:

Your Present Address:

City:

State: Pin: rw

Telephone: Mobile: 91
E-Mail:

Payout Details

Payout Option: E-Transfer: Pay Direct card:

A/c Name A/c No

Bank Name & Address

Bank IFSC CODE

Payment & Referral Details IN -

Referred By: Euro I.D Name

Accommodate By: Euro I.D Name

Received:
Cheque (or) D.D(or) NetTransfer Bank Name

I agree to the term&conditions, which have been clearly explained and accepted to me.
For Terms&conditions Refer Company Website. Applicant’s Signature & Date

Euro Pay Associates – Chinnasamy Gownder Building 1st Floor, 1b Arokiyasamy Street,
N.S.R Road Saibaba Colony, Coimbatore – 641038. TamilNadu, India.
E-mail: europayinc@gmail.com, europayassociates@gmail.com URL: www.europayinc.com www.europayassociates.com
Ph: 0422 – 646EURO (6463876), Customer Care: 91 9976345345 Customer Support: 91 98434 50555

For Office Use: _ _ _ _ _ __ _ __ _ __ _ __ _ __ _ __ _ __ _ __ _ __ _ __ _ __ _ __ _ __ _ _