ARIAN Membership Portal

MEMBERSHIP APPLICATION FORM

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Passport Must Be: jpg, png, jpeg only and must not be more than 1mb

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Signature Must Be: jpg, png, jpeg only and must not be more than 1mb

FULL NAME *

CONTACT ADDRESS *

PHONE NUMBER *

EMAIL *

PLACE OF BIRTH

DATE OF BIRTH *

GENDER *

STATE OF ORIGIN *

MARITAL STATUS *

NATIONALITY

TYPE OF AGENT *

PRESENTLY FULL TIME/PART TIME

NAME OF INSURANCE COMPANY REPRESENTING *

STATE OF OPERATION *

NUMBER OF YEARS AS AN INSURANCE AGENT

ACADEMIC QUALIFICATION *

PROFESSIONAL QUALIFICATION

Note: Each individual uploads must be of type: PDF only and must not be more than 1mb each

GOVERNMENT RECOGNIZED ID: *

COMPANY ID OR LETTER: *

CIIN CERTIFICATE *:

UTILITY BILL (FOR CONTACT ADDRESS): *

COMMISSION STATEMENT (OPTIONAL):

DECLARATION

I hereby apply to become an Individual /Associate member of the "ASSOCIATION OF REGISTERED INSURANCE AGENTS OF NIGERIA" and agree to abide by the Rules and Regulations of the Assciation.

Already An Agent:

MEMBERSHIP APPLICATION FORM

DECLARATION