Distributor Application Form

All fields with (*) are required fields.



Account Type
  
  Check if this account is an extension
Account Activation
Purchased Code from i-fern Teller
Select Arrangement *
TLR LLL RRR

Arrangement is required for PREMIUM accounts defaults will be set for initial registration
Default Arrangement
TLR
Arrangement is required for PREMIUM accounts
Disclaimer


Personal Details
     Male            Female

18 And Above Only

@

Sample format: 09xx-xxx-xxxx

Secondary mobile # if any

Enter fullname

Relationship to owner

Address Information
Account Details
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Choose your username wisely, as this cannot be changed. Username is case-sensitive.

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  I agree to I-FERN Data Privacy Policy
  

  I agree to "I-FERN Principles, Policies & Procedures". (Please read and click the link before ticking the box)