The iCon System : regis

AGENT REGISTER

STEP 1. Check Sponsor Agent Detail

Agent ID: 100843

Name: สุรชัย ศรีวิโรจน์

Mobile: 0625513856

STEP 2. Agent Profile

Please complete the form below

Title Name *

Name * (English only)

Sirname * (English only)

Sex *

Birth of date*

Passport ID *

STEP 3. Agent Address

Address * (English only)

Address2

Road

Sub-District * (English only)

District * (English only)

Province/City * (English only)

Postcode *

STEP 4. Shipping Address Use address same Agent Address

Address * (English only)

Address2

Road

Sub-Distric * (English only)

Distric * (English only)

Province/City * (English only)

Postcode *

Country

Email *

Mobile Phone *

LINE ID:

STEP 5. Agent Bank Account (Can fill later)

Account Name

Account No (Bank of Thailand)

Bank Name(Bank of Thailand and fill in numbers only Do not enter special characters)

STEP 6. Agent agreement

Agent agreement

I have studied the application rules and Check all the information as true in all respects and click the "Save data" button to confirm the application.