Become An Agent/Retailer

Applicant Name (required)

Propose Address (required)

Phone (required)

Any Experience selling lotto? (required)

Have you previously owned/operated a Lottery terminal? (yes), please state the reason for termination (required)

National Registration No (required)

Tin Number (required)

Business Type - ( ) Y ( ) N ? (required)

If Y, Contact Person {Owner, Partner, Manager} (required)

Contact Persons - Home Address (required)

Contact Home Phone (required)

Mobile (required)

Your Email (required)