AGENCY APPLICATION FORM

EbbbTesñIsMueFVICaPñak;garEckcay

AGENCY APPLICATION FORM

eKatþnamnignam (Full Name)      : ___________________________   ePT (Sex)                  : ___________

b½NÑsMKal;xøÜn (ID/Passport)      : ___________________________   sBa¢ati (Nationality) : ___________

éf¶ExqñaMkMeNIt (Date of birth)    : ___________________________   Gayu (Age)               : ___________

sßanPaBRKYsar (Marital status) : ___________________________    muxrbr (Occupation) : ___________

GIuEml (Email)                           :___________________________    elxTUrs½BÞ (Tel)        : ___________

Gas½ydæanbc©úb,nñ (Current address) :______________________________________________________

If the retailer is a registered company:

eQµaHRkumh‘un (Company Name): ________________________________________________________

b½NÑsMKal;Rkumh‘unelx (Company Registration Number) :_____________________________________

cuHéf¶TI (Date of Registration): _____________________elxKNnI (Bank Account No.):____________

RbePTPñak;gar (Type of Agency) :                       tUb (Shop)                      bBa¢r (Outlet Counter)

                                                                           

sMeNIrsMuTItaMgRbtibtiþkar (Proposed Operation Locations) :

1. _________________________________________________________________________________

2. _________________________________________________________________________________

3. _________________________________________________________________________________

4. _________________________________________________________________________________

5. _________________________________________________________________________________

bBa¢IrayeQµaHRTBü (List of Company/Personal Assets) :

RbePTénRTBü Nature of asset	B’tmanlMGit Details	tMél Value ( USD )
1.
2.
3.
4.
5.
6.
Total

éføcMNay (Fee Paid) :

tMélkk;tUb (Terminal Deposit) :                                                                                   $_______________

cMnYnluykk; (Sales Credit Deposit) :                                                                             $_______________

tMélsMusiT§i (Franchise Fee) :                                                                                         $_______________

tMélP¢ab;ExSkabGubTic (Fiber Optic Connectivity Fee/SIM Card) :                               $_______________

kEnøglk; (Sales Bench) :                                                                                              $_______________

tu nigekAGIC½rcMnYnR)aM (Counter Table & Plastic Chairs) :____________                        $_______________

sMPar³kariyal½y (Stationery):                                                                                      $_______________

epSg² (Others): (________________________________________)                         $_______________

Total:                                                                                                                          $_________________

esckþIRbkas (Declaration) :

´ ________________________________ sUmFanaGHGagfaB½t’manxagelIenHBitCaRtwmRtUvBitR)akdEmn RbsinebImanB½t’manNaminBiteyIg´nwgTTYlxusRtUvcMeBaHc,ab; énsaCIvkmµeqñat Epnkm<úCalImItFIt (I make this solemn declaration conscientiously believing the same to be true and hereby agree to abide by all the agency rules and regulations of Pan Cambodian Lottery Corporation Limited)

htßelxa (Signature) : ____________________                     éf¶cuHhtßelxa (Date):  _____/_____/____      

___________________________________________________________________________________

eRbIR)assMrab;;kariyal½y (For office use) :

erobcMeday (Processed by)      : __________________________________________________________

htßelxa (Signature)                : ____________________________    éf¶ExqñaM (Date)­­­­­­­: _____/_____/_____

yl;RBmeday (Approved by) :__________________________________________________________

htßelxa (Signature)                : ____________________________    éf¶ExqñaM (Date): _____/_____/_____

éf¶cab;epþIm (Effective date)      :_____________________________   elxPñak;gar (Agent Code):________

karyl;RBmpþl;nUvTItaMgRbtibtþikar (Approved Operation Locations) :

1. _________________________________________________________________________________

2. _________________________________________________________________________________

3. _________________________________________________________________________________

4. _________________________________________________________________________________

5. _________________________________________________________________________________

elxsMgat;Pñak;gar (Agent Code) :_____________________________      

elxsMgat;tUb (Terminal code) :

1. ___________________________________________ 2.___________________________________________

3.___________________________­_ 4____________________________ 5._____________________________

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