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)

Passport-size Photo (optional) Upload a clear JPG, PNG, WebP or PDF file (max 8 MB).

National ID *

Upload both sides separately or one combined file containing the front and back.

Upload front and back separately (optional) Upload one combined file (optional)

National ID (front) (optional) JPG, PNG, WebP or PDF (max 8 MB).

National ID (back) (optional) JPG, PNG, WebP or PDF (max 8 MB).

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: 15 Nov 2026

HOSIPOA HMIS Sales Agent Registration

AGENT DETAILS

Thank You!