Full Name

Email Address

Gender Gender Male Female Others

Country

Zone

District

City/Village

Ward No

Mobile No

Whatsapp/Viber No

Business Name

Business Address

Business Registration No[PAN/VAT]

Business Type/Category

Business website (If any)

PAYMENT METHOD USED PAYMENT METHOD USED eSewa IME Pay Khalti Prabhu Pay Bank Deposit

Others If any(For National & International Agent)

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