EmailMe Form - LoadMeUp LoadCentral Wallet order form

LoadMeUp LoadCentral Wallet order form

Retailer Information

Name *

Prefix

First *

Last *

Suffix

Product *

Retailer # *

for 0920*** place 920
for 63920*** place 920

Amount of Loadwallet to purchase *

Yahoo Messenger Account:

Facebook Email

Payment Informations

How you paid it?

Payment Method *

Amount Sent *

Reference # *

SmartMoney: Place Reference #
SmartMoney(BDO) Trans Code (Example:0102 00034 BDO 00567)
BDO Deposit: Place the Branch/ Branch Code

Dont know what to put here? Just put "on notes" here and copy the whole message/receipt in Other Notes

Date/Time of Deposit (BDO)

YYYY

AM/PM

For BDO Deposit

Other Notes

I have read the text below

Loadwallet Request will be sent upon verification of payment when we go online (takes 1-9hrs if were offline) and (takes 5mins to 2hrs if were online)

Image Verification
	Please enter the text from the image: [Refresh Image] [What's This?]

EMF Online Form

Report Abuse