ACCOUNT UPDATE FORM

BUSINESS/COMPANY NAME

: ____________________________________________

(If applicable)

NAME OF OWNER

: ____________________________________________

(or Authorized Representative)

E-MAIL ADDRESS

: ____________________________________________

COMPLETE ADDRESS

: ____________________________________________

REGION

: ____________________________________________

CONTACT NO(s)

: ____________________________________________

Registered Username

: ____________________________________________

Current Account Name

: ____________________________________________

(In confirmation messages, i.e. You are now a retailer of My Preferred Name)

New Username to Register

: ____________________________________________

(If requested to register a replacement account)

Preferred Account Name

: ____________________________________________

(In confirmation messages, i.e. You are now a retailer of My Preferred Name)

DATE

REMARKS:

: ____________________________________________

_____________________________(TO BE FILLED UP BY UNIWIZ OFFICER)_____________________________

__________________________________
CLIENTS SIGNATURE OVER PRINTED NAME
(or Authorized Representative)

__________________________________
ACCOUNT OFFICER