AGENCY APPLICATION FORM

Agent's Onboarding Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Local Government Area (LGA)*
Select the zone in Local Government Area*
Next of Kin
Next of Kin Phone number
Gender*

MaleFemale
Are you above 18 year old?*

YesNo
NOTICE

Each TERMINAL sale attracts an additional INCENTIVE on a DAILY BASIS, you stand a chance to EARN MORE. Please note that the POS is not for sale and the POS remains the property of LibertyPay until after 2 years of active use, the ownership will then be transferred.
Should be Empty:

Agent's Onboarding Form