Distributor Registration Form

Regis Paris Institut de Parfumerie
Registration form for dealers and representatives
Full Name
First NameLast Name
Do you have a Facebook account?
Facebook username
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
E-mail
Representative and Recruiter (important info for compensation plan)
Your recruiter will receive a notification so please enter a valid email, thank you
Your recruiter is
Your recruiter
First NameLast Name
E-mail of your recruiter
Order Details
(You can order up to 10 different products)
Product 1
Quantity for product 1
Product 2
Quantity for product 2
Product 3
Quantity for product 3
Product 4
Quantity for product 4
Product 5
Quantity for product 5
Product 6
Quantity for product 6
Product 7
Quantity for product 7
Product 8
Quantity for product 8
Product 9
Quantity for product 9
Product 10
Quantity for product 10
Payment Details
Payment mode
Please send your payment to: Regis Peugniez address: 119 Bayabong Street Ayala Alabang Village Muntinlupa City 1780 Philippines telephone: 9205510048
Please note that we will only ship once we receive te control number, thank you!
Please coordinate with you recruiter or directly with Regis Paris contact number 09205510048 for meet up, thank you
Tick the box to accept the Terms and Conditions of Regis Paris
Order Date
DayMonthYear
To read our terms and conditions click here
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Regis Paris Institut de Parfumerie