Brand Affiliate ID:

RO3388223
75 W. Center St. Provo, UT 84601

Please Fax to 0800 895185

BRAND AFFILIATE AGREEMENT -- ROMANIA

New Account Information 

Name: IORDACHESCU ROXANA

Social Security Number: XXXXX734

Mobile Telephone 749096509 Sponsor’s Name:  SC ASC CLINIC SRL

Address: GH. LAZAR NR.7 Sponsor’s ID:  RO1006525
BRASOV, RO 500090
Email/Login ID:  roxanaiordachesu@brasov.r
o
Date of Birth:  22 May, 1983

Sign Up Date:  13 Mar, 2019