BAXIBOX POS AGENT REGISTRATION FORM
Email address *
Full Name *
Your answer
Phone Number *
Your answer
Username *
Your answer
GENDER *
Your answer
Date of Birth (DD / MM / YYYY) *
Your answer
Designation *
Outlet Type *
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
Longitude (E.g, Longitude of Ojota, 1.0000 N) *
Your answer
Latitude (E.g, Latitude of Ojota, 0.5000 E) *
Your answer
State
Your answer
Registration Date (DD/MM/YYYY) *
Your answer
Bank Verification Number (BVN) *
Your answer
Bank Name *
Your answer
Bank Account *
Your answer
How do you get to know us? *
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.