Registration form for a business provider account

Company details


Persons authorised to represent the company

Last name First name Fonction Personal phone
direct
Signature
Individual
Collective
Individual
Collective
Individual
Collective
Individual
Collective
Individual
Collective

Bank identity details

Login information

  • Must contain at least 6 characters
  • Must contain uppercase and lowercase
  • Must contain numbers
  • Tip: add special characters such as: *-/^
  • Tip: use more than 12 characters

yes      no