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Agent Registration Form


 AGENT INFORMATION:
Company Name:  
RC Number:  
PIN:  
Trade name:  
Business Segment:  
 
If OTHER, please type:
  MAIN ADDRESS:
Address:  
   
Postal Address: P.O. Box:      Postal Code: 
City:  
Country:
Years at present address:
Years
 BANK ACCOUNT:
JamiiBora Customer:
Yes   No
Account Number:
UBA Branch:
Type of Account:  
Current Account: Saving Account:
SMS Alert on POS  
  Mobile Number for SMS Alerts:   +254
 
  MAIN CONTACTS:
         Primary Contact:
Name:
Designation:
Office Phone Num.:  
+254 Ext:
Mobile Number
+254
e-Mail Address

         Secondary Contact:
Name:
Designation:  
Office Phone Num.:  
+254 Ext:
Mobile Number
+254
e-Mail Address
 
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