Subscribed and sworn to before me this ____ day of ________________, 20____ in

____________________________, affiant exhibiting to me his/her Community Tax Certificate No. ___________________

issued on ________________ in __________________.

Notary Public

Doc. No. __________

Book No. __________
Page No. __________
Series of __________

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Globe Store : ____________________________

Date and Time Received : ____________________________
ID Presented : ____________________________

Attending CSR*: Store Head/ OIC:

_________________________ __________________________
(Signature over printed name) (Signature over printed name)
*Submit fully accomplished and notarized form to MYNT GCASH FRAUD TEAM G-XCHANGE, INC. 32/F The Trade and Financial Tower
32nd Street corner 7th Avenue Bonifacio Global City, Taguig 1634