ZipX Curaçao ~ House Membership Registration Form

Customer Profile
P.O. Box Applied For:	Company
	Individual (Credit Card Required)

Company Name:
Individual Name:
1.	Date of Birth:
2.	Date of Birth:

Business Information
Street:
Office Building:
Floor:
Suite:
Town/District/Postal Code:
Telephones:	Ext:
Fax:

Home Information
Address:
Town/District/Postal Code:
Telephones:
Other (Cellular):

Email Information
Email (Business):
Email (Personal):

Delivery is available upon request only and arrangements must be made before 1600 hours on the day prior to the requested delivery date. Please note there is a delivery charge of NAFL 6.00 per delivery to any address in Curaçao!!

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By submitting this form, you acknowledge that you have read, understood, and agree to accept the Terms and Conditions of this agreement.