2 SUBSCRIBER REGISTRATION FORM airtel Airtel Uganda Plot 40 Jinja Road P.O Box Kampala (U) Tel: +256 7s 2220110 Fax: +266 75 2294093 wwwafricaaitelluganda Serial No, PLEASE FILL OUT THE APPLICATION FORM IN CAPITAL LETTERS. Activated Phone number [0 [7 [5 {olz New Sim card [] old sim card () {o|7 Alternative Mob. Number: First Name Last Name a | DONNY Gender Male EJ} Female Bhyscal/ Plot street Nome & No: village esidentia , Address P.O. Box District LCs Zone Business Address Email Type of PhotoiD [1] Nationality 1 Passport (Compulsory for Foreigners) Recommendation from village chairperson/LC Drivers’ Licence 1 others, pis specify Dy Voter Registration Card 1 Vilage 10/ student 10 Employee i0/ Letter from company with photo []_NssF/Pension Card ID Number 1 National 10 Declaration. ‘# For personis) under eighteen (18) years - registration should be| the presence of parent or guardian whose name and contact should be recorded {hereby confirm that the information provided aboveis true and correct and wish to register for Airtel Uganda Services and Airtel Money on the terms and conditions specified in the Airtel Uganda Terms and Conditions of Use attached hereto an |agree to abide bythe fll terms and conditions avallableon the Airtel Uganda website; wwe atria airtelfugande contained therein, This Registration Form together with the terms and conditions constitute a binding Agreement between me and Airtel Uganda, Applicant's authorised signatory Signature s NN Date Agent's details Distributor Name/Code Agent ID Agent mobile ToT 7S Ihave seen and verified the applicant’ original identification documents Agent Signature Date SUBSCRIBER REGISTRATION FORM CUSTOMER COPY Acted pone number 0 [7 [8 (ols agentnodie[o]7 [5 newsincas) osmenel) — [0 [7] Ihave seen and verified the applicant's orginal identfeaton documents. [Lthave ead and understood the terms and condton. fopians Signatre ote Agent signe owe