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Part 1. Agent Information


Fields with * are required.

Agent Name *

Mobile/Company Tel No. *

Official Email Address *

Residential/Company Address *

Years in Business *

Expected Daily Volume *

Trade Name (if different from Company Name) *

Business Structure *

Sector *

Name of Business (Industry Category) *

Types of Products/Services *

Tax ID No. (TIN) *

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Part 2. Contact Information


Fields with * are required.

Authorized Representative (if any) *

Position *

Contact No.*

Email Address *

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Part 3. Business Transaction Information


Fields with * are required.

Average Reload Value*

Highest Purchase Value*

Reload Methods*

Annual Sales*

Number of Transactions (per month)*

Target Market*

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Part 4. Business Transaction Information


Fields with * are required.

Name of Bank *

Branch/Address *

Account Name *

Account Number*

Account Type *

Frequency of Settlement *

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Part 5. Wrap-Up


Agent Information


Agent Name

Mobile/Company Tel No.

Official Email Address

Residential/Company Address

Years in Business

Expected Daily Volume

Trade Name (if different from Company Name)

Business Structure

Sector

Name of Business (Industry Category)

Types of Products/Services

Tax ID No. (TIN)




Contact Information


Authorized Representative (if any)

Position

Contact No.

Email Address




Business Transaction Information


Average Reload Value

Highest Purchase Value

Reload Methods

Annual Sales

Number of Transactions (per month)




Primary Settlement/Sending Bank Account


Name of Bank

Branch/Address

Account Name

Account Number

Account Type

Frequency of Settlement