Life Mates Payment Form
Member #
*
Member Name
*
First Name
Last Name
Today’s Date
-
Month
-
Day
Year
Member Email
*
example@example.com
Paid Amount
*
Introduction Fee
*
Match Maker Name
*
Match Maker ID #
*
Initials
5 Digit Number
Member Phone Number
*
Sex
*
Male
Female
Membership Options (入会形態)
prev
next
( X )
Choosing
(
¥
150,000
JPY
one-time payment)
(A) Platinum Choosing 1 Year / Intro Fee 4,000 1年間有効、紹介チャージ @4000円
Choosing
(
¥
100,000
JPY
one-time payment)
(B) Gold Choosing 6 Months / Intro Fee 5,000 半年間有効、紹介チャージ @5,000円
Members Choose You
(
¥
80,000
JPY
one-time payment)
(C) Platinum Choose Me 1 Year / Intro Fee 4,000 1年間有効、紹介チャージ @4,000円
Members Choose You
(
¥
40,000
JPY
one-time payment)
(D) Gold Choose Me 6 Months / Intro Fee 5,000 半年間有効、紹介チャージ @5,000円
Submit
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