DXN INTERNATIONAL PRIVATE LTD. 498 Quezon Aver, Say. Sou Tangle Quezon Cy, Pines ‘Tat Nox: (62) 73.0444 /a7agUtT Io 19 Fax Na-STocR20 eben incom www cape DISTRIBUTOR REGISTRATION FORM 1x1 Note: Compete the frm claty and in block laters. incomplete form wil pot be processed on time. Be Photo ‘tt fo read XN Ditutrhip Rules end Regulation ound ovr! pre sig ts Apleaton ‘Form The Compr wif ony proces te apolcaton pen payman of he Mombaraip feo Date: (as Nome) Name CI iil ‘Fier ame) [ Eedes) Lied a a 1 (Month, Day, Yeer) Birthdate Age [_[_] sex [JF IM Status single [_] Mentor Widow (Residence) (fice) (Compulsory Mobil (Emit Address). Contact Nos. I (House Nuriber Block Number Steet Postal Address z (ilege, Barangay, Baio) ee Town, cio Province) 1 Teoof ooletl T_T. Zip Code Taxpayer's Identification No. Nationality ] (ast Name, Fit Name, Mie Nama ‘Spouse Name Teele (Went Ba ‘Spouse's Birthdate [ i ‘Sponsor Code (Lest Neme, Fist Name t J Tal Aad Contact Nos. (Please provide one bank account only) Cox e-Point (Banco de Oro ATM Account [Account Number: ‘Bronch: (BPI Bank ATM Account least West Bank ATM Account Crcec atm Account ‘Bofors affixing your signature, plosse read the DXN Distributorship Rules and Regulations stated atthe back page. warn’ ad represen fat have bd and understood and wil uly comply wih OXN Rules and Regulators DXN Code of Ee (os peda he dara sig) and te DAW ‘Maretng Plan and bat Rave reviewed read and understood te canara tert wich areal conpded in the OXN Starter Kt fo, vaste thal Intomtonsupeles orem arte ana conor en autote OXN 1 dere ha appieatn oom te cen wal be pow fake alecrg nomen “Disrcars Sanat Oe PRES Nae ‘Spans Sri Over Pred Nari app] “Sponsor Date Received Processed by: Signature Over Prted Name_Sighature Over Printed Name_|Received by: Distributor Code ‘Wi Hess Ofce Yellow Secs Centr Pk iruor Revised July 29, 2015