EVD RESELLER REGISTRATION FORM Section 1: Name: Customer Details Registration Date: ___/____/20___ Address: Contact Number: Email: (if any) Section 2: Customer Identification Please present any of one of the following. Tick below Driver’s License Student ID License #: ID #: Nasfund ID Nambawan Super ID ID #: ID #: Section 3: Purchasing Details Resale Location: Amount: Employment/Work ID ID #: Other ID ID #: K____________ Section 4: Customer Marketing Feedback How did you hear about becoming a reseller? (Please Tick) Newspaper Billboards Facebook Flyers/Posters Friends/Wantoks SMS Broadcast Radio Roadshows Name: Signature Date: ___/____/20___ Bmobile-Vodafone Representative: Signature: OFFICE USE Bmobile-Vodafone Number: (for EVD Use) Date: ___/____/20___ Receipt Number: Merchant #: You are confirming having received the full amount stated in this document and transferred the purchased amount to the Bmobile-Vodafone mobile number nominated in this document (reseller). You have provided the reseller with all products and services associated to this purchase. Please tick as confirmation Customer Tick as proof of receipt Customer Signature Account Created Merchant Number PIN Number EVD Top Up received
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