पेशागत बीमा अभिकर्ता संघ नेपाल

Taxpayer & Agency Registration Form For Membership

Agency-Registration

Membership Registration

Agency Name*

Agency Code*

Gender *

Mobile No (NTC/Ncell)*

email

Marital Status*

Date of Birth (BS)*

DOB (AD) M-D-YY

Citizenship No

Issued District

Issued Date

Full Address*

Current Address

Qualification*

Profession

Select Languages

Nepali

Hindi

Tharu

English

Religion*

Insurance Company*

Working Branch*

Agency Level*

Blood Group

Grand Father's Name*

Father's Name*

Spouse Name

Spouse Father's Name

Training Date/Venue

Agent License No

License Issued Date

Policy Start Date

License Expiry Date

Bank Name*

Agency Name As Bank

Branch & A/c No.

PAN NO

Submit Date

Membership Year

Due/Payment Year

Membership Fee

Renual Year

Citizenship

License Photo

Membership ID

Pan Card Photo

Amt. Payment Slip

Upload Photo*

This field should be left blank

QUICK LINKS FOR EASY PAYMENT:

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