Personal Information: Please Verify The Information Before Final Submission

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Please verify the information before final submission.


Personal Information
Your Sponsor
Mr Sandeep Babubhai Halpati
Address one:
masjid falia (dnh)
First Name:
Mr pratik
Address two:
silvas
Middle & Last Name:
jayanti patel
City:
selvas
Father / Guardians Name
jayanti parbhu patel
State
Dadra and Nagar Haveli
Nominee
jayanti-Father
Mode of Correspondence
Courier
Contact Number
9033585005
Postal Code
396230
Email
NA
PAN
NA
Date of Birth:
7-7-1994
Selected Sponsor's Leg:
Left
eBIZ Account Details
Username:
tiktik321123
Password:
tiktik321123
Payment Information
Demand Draft Number
504985
Issuing Bank:
sbi
Issuing Date:
19-5-2014
Amount:
10675.00
Issuing Bank Branch:
sbi
Indicate by checking this box that you are atleast 18 years of age and have completed
atleast 10th grade of schooling and agree with the given Terms and
Conditions and FAQs applicable to eBIZ.com Pvt. Ltd. Please note that the product can not be
purchased on joint name or partnership. Further note that if your spouse has purchased the
product, you are restricted to buy. (Violation of this would amount to forfeiture of any earned
commission as explained in our Legals and FAQs).

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