पेशागत बीमा अभिकर्ता संघ नेपाल Taxpayer & Agency Registration Form For Membership Agency-Registration Membership Registration 1. MEMBERSHIP PROFILEAgency Name*Agency Code*Gender *Select Gender MaleFemaleOthersMobile No (NTC/Ncell)*emailMarital Status*Select Marital StatusSingle/अविवाहितMarried/विवाहितDivorced/सम्बन्ध विच्छेदWidowed/एकल महिलाWidower/विदुरDate of Birth (BS)*DOB (AD) M-D-YYCitizenship NoIssued DistrictIssued DateFull Address*Current AddressQualification*Select QualificationSecondary/माध्पामिक तहHigher Secondary/उच्च माध्पामिक तहIntermediate/प्रमाणपत्र तहBachelor's Degree/स्नातकाेत्तर तहMaster's Degree/स्नाकाेत्तर तहMaster of Philosophy/ दर्शनशास्त्रमा स्नाकाेत्तरDoctor of Philosophy/ विद्यावारिधी-ProfessionSelect ProfessionFarmer-किसानArmy/Police-सेना/प्रहरीBussinessman-व्यापारीCharter Accountant-चार्टर एकाउन्टेन्टDocter-डाक्टरDriver-चालकEngineer-इन्जिनियरForeign Employment-वैदेशिक रोजगारीGovernment Service-सरकारी सेवाHousewife-गृहिणीJournalist-पत्रकारLawyer-वकिलPilot-पायलटPrivate Service-निजी सेवाProfessor-प्रोफेसरStudent-विद्यार्थीSocial Worker-सामाजिक कार्यकर्ताTeacher-शिक्षकOther-अन्य-Select Languages*NepaliHindiTharuEnglishReligion*Select ReligionHinduMuslimBuddhistKristianKiratOther ReligionInsurance Company*Select Insurance CompanyAsian Life Insurance CompanyCitizen Life Insurance CompanyHimalayan Life Insurance Ltd.IME Life Insurance CompanyLife Insurance Corporation Ltd.MetLife CompanyNational Life Insurance CompanyNepal Life Insurance CompanyRastriya Jeewan Beema CompanyReliable Nepal Life InsuranceSun Nepal Life Insurance CompanySuryaJyoti Life Insurance Co. Ltd.Other Life Insurance-Non-Life Insurance CompanyWorking Branch*Select Working BranchNepalgunjKohalpurBansgadiGulariyaRajapurSurkhetDailekhDangKailaliDhangadhiMahendranagarOther Life Insurance Branch-Non-Life Insurance BranchAgency Level*Select Agency LevelAgent-अभिकर्ताBC-Bussiness Co-ordinatorAM-Agency ManagerSAM-Senior Agency ManagerMDRT-Million Dollr Round TableCOT-Court Of The Table (3)TOT-Top Of The Table (6)-Non-Life Insurance AgentBlood Group *Select Blood Group A+B+AB+O+A (-)B (-)AB (-)O (-)Unknow-Grand Father's Name*Father's Name*Mother's NameSpouse Or Nominee NameSpouse Father's NameTraining Date/Venue Agent License No License Issued DateLicense Expiry DateAgent's 1st Policy DateBank Name*Select Bank NameAgricultural Development Bank Ltd.Century Commercial Bank Ltd.Citizens Bank International LimitedDeva Bikas Bank LimitedEverest Bank Ltd.Gandaki Bikas Bank LimitedGarima Development Bank Ltd.Global IME Bank Ltd.Himalayan Bank LimitedICFC Finance LimitedJyoti Bikas Bank LimitedKailash Bikash Bank LimitedKamana Sewa Bikash Bank LimitedKarnali Development Bank LimitedKumari Bank LimitedLaxmi Bank LimitedLumbini Bikash Bank LimitedMachhapuchchhre Bank LimitedMahalaxmi Bikas Bank LtdManjushree Finance Ltd***Mega Bank Nepal LimitedMuktinath Bikas Bank LtdNabil Bank LimitedNepal Bangladesh Bank LimitedNepal Bank LimitedNepal Credit & Commercial Bank LimitedNepal Investment Bank Ltd.Nepal SBI Bank LimitedNLIC Asia Bank Limited*NMB Bank LimitedOm Development Bank LimitedPrabhu Bank LimitedPrime Commercial Bank LimitedRastriya Banijya Bank LtdSanima Bank Ltd.Shangrila Development Bank Ltd.Siddharth Bank LimitedShangrila Development Bank Ltd.Sunrise Bank LimitedOther BankNOT NOW-Agency Name As BankBranch & A/c No.PAN NOSubmit DateMember YearPlease selectSelect Membership YearFY-2079/80FY-2080/81FY-2081/82FY-2082/83FY-2083/84FY-2084/85Other-Old-Due/Pay YearPlease selectSelect Due/Pay Year1 Year2 Year3 YearAbove 3 Year-Membership FeePlease selectSelect Membership FeeRs. 300/- First MembershipRs. 150/- For Renewal 1 Yr.Rs. 300/- For Renewal 2 Yrs.Rs. 450/-For Renewal 3 Years.Rs. ............../- Agency ID-CardRs. ............../- New MembershipRs. 550/- Membership With IDRs. ............../- 3 Years Membership With IDRs.5500/- Lifetime Membership With ID-Expiry YearSelect Expiry YearFY-2081/82FY-2082/83FY-2083/84FY-2084/85Other-Paid AmountRemarkSelect RemarkDue AmountFinal AmountSIGroup TEAM-PHOTO *दुबै कान देखिने फोटोCitizenship-FCitizenship-BLicense PhotoMembership IDPan Card IDPayment SlipSendThis field should be left blank RENEWAL AND UPDATE 2. MEBERSHIP UPLOADID_CODE*FULL NAME*Grand Father*Branch*PAN NOPhoto*Citizenship-F*Citizenship-B*Pan Card ID*License PhotoMembership IDPayment SlipNoticeSIGroupThis field should be left blank QUICK LINKS FOR EASY PAYMENT: Just Click Nepali Home Page English Home Page Health Insurance81 Zoom Program-081