Become Our Agent | EGL Africa

Agent Application Form

Prefix

First Name *

Last Name *

Email *

Phone

WhatsApp Number

National Identification Number (NIN)0 / 11

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

Date Of Birth

GenderMaleFemale

Have you ever been appropriately convicted for criminal offence?YESNO

If your answer to the above question is YES, please briefly specify the crime0 / 200

Employment StatusEmployedUnemployedSelf Employed

Your Company/Workplace Name

Your Company Website

Company Phone

Work Address

City

State/Province

ZIP / Postal Code

Country

Bank Name

Account Number0 / 15

Account Name (Must be yours)

Upload a valid ID Card

International Passport, National ID Card, Drivers License or Work ID Card