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Personal Information
Name * Last Name First Name
Middle Initial
E-mail Address * (must be valid)
Sex *
Civil Status *
Date of Birth *  –   –  (mm-dd-yyyy)
Company *
Title/Designation *
Telephone No. (day) *
Telephone No. (night) * same as day phone
Mobile No.
   
HOME * OFFICE same as home
Address 1
Address 1
Address 2
Address 2
City
City
Zip/Postal
Help?
Zip/Postal
 Help?
 
Outside the Philippines
   

When shopping do you usually shop at Discount stores, Malls, Department Stores or on the Internet ? *

Discount Stores
Malls
Department Stores
Internet

How do you usually pay for your purchases ? *

Cash
Check
Debit Card
Credit Card

What is your total household income?

Below P15,000.00
P16,000.00 - P30,000.00
P30,000.00 - P75,000.00
Above P75,000.00
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