EmailMe Form - E-Load Business Registration Application

Choose the Company *
Loadcentral E-Loading
Choose which E-loading company you are going to join
Phone (Enter the mobile number you want to register as a retailer) *
This applies to both Postpaid and Prepaid mobile number. Just enter the 11 digit mobile number.
Full Name (First MI. Last) *
Type of (Scanned) Valid ID/Government ID Submitted *
Valid ID Number *
Please enter number indicated on the ID you chose as proof of identification. This must match with the scanned valid ID you will send.
Upload Scanned Valid ID/Government Issued ID
Please take note that only .jpg or .jpeg format are allowed. You may send the scanned ID next time if not available this time.
Current Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Enter valid mailing address here.
Region *
Enter your current region, e.g. Manila = NCR
Date of Birth *
MM / DD / YYYY
Gender *
Male
Female
Occupation / Business *
Registration Payment Method Used (Please pay P100 or $2.95 for your registration. *
Note that we will only process paid registration.
Please send your payment to:

All Account name: Eldefonso S. Roberto

SMARTMoney Account #: 5577-5155-1756-2137
Paypal Account: bills @ ppeso.com
Paid Date and Time *
MM / DD / YYYY HH : MM AM/PM
Enter the details of your payment.
Payment Reference or Acknowledgment No. Write N/A if not applicable. *
Valid Email Address *

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