BIEN Payment Solutions - Agent Application Form

Instructions:

Complete this form in BLOCK LETTERS using black or blue ink
All fields marked with asterisk (*) are mandatory
After completing, scan or photograph this form in clear, readable quality
Upload the scanned form along with other required documents on our online registration portal
Ensure all information provided is accurate and verifiable

1. PERSONAL INFORMATION

First Name: *

Middle Name:

Last Name: *

Date of Birth: *

Gender: *

National Identification Number (NIN): *

Tax Identification Number (TIN): *

2. CONTACT INFORMATION

Primary Phone Number: *

Alternative Phone Number:

Email Address: *

3. LOCATION & RESIDENCE DETAILS

Physical Address: *

Village/Town: *

Parish/Ward:

County/Subcounty:

District: *

Region: *

Central

Eastern

Northern

Western

Nearest Landmark:

4. BUSINESS INFORMATION (If Applicable)

Do you have an existing business?

Yes

Business Name (if applicable):

Business Type:

Years in Operation:

5. BANKING INFORMATION

Bank Name: *

Account Number: *

Branch:

6. REFERENCES

Reference 1 (Local Council/Religious Leader/Employer)

Name: *

Position/Title:

Phone Number: *

Relationship:

Reference 2

Name: *

Position/Title:

Phone Number: *

Relationship:

7. DECLARATION

I hereby declare that:

All information provided in this application is true, accurate, and complete to the best of my knowledge.

I understand that providing false information may result in the rejection of my application or termination of my agent agreement.

I have read and understood the BIEN Payment Solutions Agent Terms and Conditions.

I consent to BIEN Payment Solutions conducting background checks and verifying the information provided.

I agree to comply with all applicable laws, regulations, and BIEN Payment Solutions policies.

Applicant Signature:

Date:

Full Name (Print):