GROUP DOLL DATE REGISTRATION FORM

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Payment Plan *

Pay In Full ($750 upon completion of this form)

Pay In Two Installments ($375 now, $375 on January 15th)

I agree to the payment terms and authorize POSH PR® to use my card on file. *

Yes

No