Back to HOME

Merchant Registration Form


 MERCHANT 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:
UBA Customer:
Yes   No
Account Number:
UBA Branch:
Type of Account:  
Current Account: Saving Account:
SMS Alert on POS  
  Mobile Number for SMS Alerts:   +254
 
  BUSINESS INFORMATION:
 
Products and services
offered
 
POS Required
  MAIN CONTACTS:
         Primary Contact:
Name:
Designation:
Office Phone Num.:  
Prefix: Number:   Ext:  
Mobile Number
Prefix: Number:  
e-Mail Address

         Secondary Contact:
Name:
Designation:  
Office Phone Num.:  
Prefix: Number: Ext:  
Mobile Number
Prefix: Number:
e-Mail Address
 
Back to HOME