Internal Use Only

For Britemz team to record new client signups

New Client Signup Form

Complete this form after receiving payment confirmation

Full Name *

Business Name *

Email Address *

WhatsApp Business Number *

Alternative Phone Number

Business Location *

Business Type/Industry

Selected Plan *

Payment Amount (KSh) *

M-Pesa Transaction Code *

Payment Date *

Subscription Start Date *

Next Renewal Date *

Paybill/Till Number

Account Reference

Client does not have Paybill/Till yet (Will help them apply)

Referred by Agent?

Agent Name

Agent Phone

Commission Rate (%)

Additional Notes / Special Requirements

Assigned Team Member *