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Payment Notification Form

Thank you for making payment for your Fragnetics service. In order to facilitate speedy setup/administration, please fill up the following as accurate as possible:

Your name:
Login Name for home.fragnetics.com (if available) :
Email Address: (e.g. pro@gamer.com)
Method of Payment:
Service Type
Date / Time of Payment and Remarks: Western Union Put MCTN number