DELATERRE ROULETTE 2013

DELATERRE ROULETTE 2013
Welcome!! If you are on this page, it means you are interested in particpating in our Roulette contest. Please fill all required questions below truthfully. Any false information will result in your instant disqualification from this contest and forfeiture of registration fees.

Minors are NOT qualified to enter this contest without proof of parental consent.

Final payment will be made to the most successful contestant. Payment shall exclude all bank charges and VAT.
Full Name*

First NameMiddle NameLast Name
GENDER*
Birth Date*

MonthDayYear
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
HEIGHT (cm)*
CURRENT WEIGHT (kg)*
WAIST (CM)*
SHOULDER (CM)
RIGHT ARM (CM)
LEFT ARM (CM)
HIP (CM)
LEFT THIGH (CM)
RIGHT THIGH (CM)
ANY EXISTING ILLNESS*
MODE OF IDENTIFICATION
ID NUMBER*
BEFORE PHOTOGRAPH*

Upload a File
clear Full-length photograph only. Photograph must show your face clearly and ankles. Cancelof
PAYMENT DETAILS*
PROOF OF PAYMENT*

Upload a File
upload receipts, teller or transaction no./payment notification. Cancelof
I have read and understood the above terms and conditions. I accept to be bound by the said terms and conditions.*

Yes
Registration Payment Information

ACCOUNT NAME: DE LA TERRE TGZ LIMITED

ACCOUNT NUMBER: 0131956714

SORT CODE: 058152104

BANK: GUARANTY TRUST BANK, NIGERIA

NOTE: Please if you're initiating transfers, ensure all charges are borne by sender. Thank you.
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