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UCCR - REGISTRATION FORM
Use this form to register your contact information
with UCCR.
Mail to: UCCR Apdo. 655-1007 San Jose, Costa Rica.
Questions: 296 1936
The UCCR is a group of investors/creditors of Luis
Enrique Villalobos Camacho, and support the effort to remove the
legal obstacles that prevent him from meeting his financial
obligations.
Please print:
Name: ____________________________________________________________
Other Names: ______________________________________________________ Address: __________________________________________________________ Address: __________________________________________________________ Home Phone: __________________________ FAX: ______________________ Cellular: ____________________________ Other: ________________________ E-Mail Address:
____________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
Signature: _________________________________ Date: ________________
THE INFORMATION PROVIDED ON THIS FORM IS STRICTLY CONFIDENTIAL AND WILL BE KEPT IN AN UNDISCLOSED LOCATION. THE INFORMATION WILL NEVER BE DISCLOSED TO ANY UNAUTHORIZED PERSON OR GROUP. UCCR Web Site: www.ticostuff.com/uccr E-Mail: uccr@ticostuff.com
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