Intermediary Registration
Complete this Password Registration Form
Register online for web access by completing this password registration form. For security reasons, you will be required to print, sign and fax the resulting activation request to
(021) 914-3524
, and your password will be activated upon receipt of your signed request.
Please complete the form below (all fields are required) and then press the Submit button
For an explanation of each form element, move your cursor over each field name
First Name
Surname
E-mail Address
Confirm E-mail
Type
Intermediary
Intermediary Number
Password
Confirm Password