Consent Form

SMART | CONVENIENCE | SAFE

Community / Organization Information

Name

Registration No.

Address

Telephone No.

Number of Members

Representative Information

Name

Telephone No.

Position

By submitting this form, we hereby declare and understand that:

* We agree to participate and enroll to ParadiseLinx Community Program.

* We agree to furnish our relevant information as may be required for registration purposes

* We have understood and are aware of the benefits, features, terms and conditions of this program.

* Any benefits, features, terms and conditions of this program may change, update or cancel from time to time as appropriate.