HMIS Sales Agent Registration

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AGENT DETAILS

Sales Agent Registration Form Kenya Sales Network

Are you registering as an Individual or a Company?

Individuals receive payment via M-PESA. Companies receive payment via bank transfer.

Individual Company

1 Agent Identification

Full Name / Company Name *

ID Number / Company Reg No. *

KRA PIN (optional)

Email Address *

Primary Phone Number *

Alternate Phone Number (optional)

Physical / Office Address *

2 Location

County of Operation *

Sub-County *

Nearest Town *

Primary Sales Region *

3 Professional Background

Years of Sales Experience *

Current Occupation (optional)

Briefly describe your sales experience *

Do you have existing healthcare clients? (optional)

4 Payment Details � Individual (M-PESA)

M-PESA Registered Name *

M-PESA Number *

ID Number Linked to M-PESA (optional)

4 Payment Details � Company (Bank Account)

Bank Name *

Bank Branch *

Account Name *

Account Number *

Bank / SWIFT Code (optional)

M-PESA Paybill (if any) (optional)

5 Authorization

Name of Authorizing Officer *

Signature *

Sign with your mouse, touch, or stylus.

Declaration *: I confirm that the information provided in this form is accurate, complete, and truthful to the best of my knowledge. I understand that any false or misleading information may lead to disqualification or legal action.

Date of Submission: 28 Sep 2026

HosiPoa HMIS Sales Agent Registration

AGENT DETAILS

Thank You!