BAXIBOX MOBILE APP AGENT FORM
Email address *
Full Name *
Your answer
Phone Number *
Your answer
IMEI Number (Dial *#06# on your phone) *
Your answer
Username *
Your answer
GENDER *
Your answer
Date of Birth (DD / MM / YYYY) *
Your answer
Designation *
Profession/Occupation *
Your answer
Home Address *
Your answer
Outlet Address Number *
Your answer
Outlet Street Address *
Your answer
Nearest Bus Stop/Landmark *
Your answer
LGA (District) *
Your answer
State *
Your answer
Outlet *
Android Phone *
Bluetooth Printer *
N/B: The Procurement of thermal Printer is compulsory as printing is an integral part of our transaction flow.
Registration Date (DD/MM/YYYY) *
Your answer
Bank Name *
Your answer
Bank Account Number *
Your answer
Bank Verification Number (BVN) *
Your answer
How do you get to know us? *
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