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Plot no. 401A St. Johns Road, Makeni Bonaventure
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FISP APPLICATION FORM
Form for Suppliers Agro-Dealers
Are you already registered on ZIAMIS ?
(Required)
Yes
No
Enter your Main Supplier or Agro -Delear code
(Required)
Company Registration Number
(Required)
TPIN Number
(Required)
Company Trading Name
(Required)
Physical Address
(Required)
Contact Person Name
(Required)
Mobile Number
(Required)
Email Address
(Required)
Do you have valid Trading Licence Certificate?
(Required)
Yes
No
Do you have valid Trading Licence Certificate?
(Required)
Yes
No
Technical Requirement
What category of supply are you in?
Agro-Chemical Supplier
Agro-Dealer
Distributor
Fertilizer Supplier
Seed Supplier
Veterinary Supplier
Do you have a valid Seed Sellers License?
(Required)
Yes
No
Do you have a valid ZEMA Certificate?
(Required)
Yes
No
Do you have a valid NAPSA Compliance Certificate?
(Required)
Yes
No
Do you have a valid Radiation Protection Authority Certificate (importers of Fertilizer)?
(Required)
Yes
No
Do you have a valid ZAMRA Certificate?
(Required)
Yes
No
Do you have a valid Seed Processing Certificate?
(Required)
Yes
No
Other Requirements
Provinces
(Required)
Lusaka
Central
Copperbelt
Southern
Eastern
Western
Northern
Muchinga
North Western
Luapula
Select All
Copperbelt Province Districts
(Required)
Chililabombwe
Chingola
Kalulushi
Kitwe
Luanshya
Lufwanyama
Masaiti
Mpongwe
Mufulira
Ndola
Select All
Western Province Districts
(Required)
Kalabo
Kaoma
Limulunga
Lukulu
Mitete
Mongu
Mulobezi
Mwandi
Nalolo
Nkeyema
Senanga
Sesheke
Shangombo
Sikongo
Sioma
Luampa
Select All
Central Province Districts
(Required)
Chibombo
Chisamba
Chitambo
Kabwe
Kapiri Mposhi
Luano
Mkushi
Mumbwa
Ngabwe
Serenje
Shibuyunji
Select All
Luapula Province Districts
(Required)
Chembe
Chiengi
Chifunabuli
Chipili
Kawambwa
Lunga
Mansa
Milenge
Mwansabombwe
Mwense
Nchelenge
Samfya
Select All
Lusaka Province Districts
(Required)
Chilanga
Chongwe
Kafue
Luangwa
Lusaka
Rufunsa
Select All
Eastern Province Districts
(Required)
Chadiza
Chama
Chasefu
Chipangali
Chipata
Kasenengwa
Katete
Lumezi
Lundazi
Lusangazi
Mambwe
Nyimba
Petauke
Sinda
Vubwi
Select All
Southern Province Districts
(Required)
Chikankata
Chirundu
Choma
Gwembe
Itezhi-Tezhi
Kalomo
Kazungula
Livingstone
Mazabuka
Monze
Namwala
Pemba
Siavonga
Sinazongwe
Zimba
Select All
Northern Province Districts
(Required)
Chilubi
Kaputa
Kasama
Lunte
Lupososhi
Luwingu
Mbala
Mporokoso
Mpulungu
Mungwi
Nsama
Senga Hill
Select All
North Western Province Districts
(Required)
Chavuma
Ikelenge
Kabompo
Kalumbila
Kasempa
Manyinga
Mufumbwe
Mushindamo
Mwinilunga
Solwezi
Zambezi
Select All
Muchinga Province Districts
(Required)
Chinsali
Isoka
Kanchibiya
Lavushimanda
Mafinga
Mpika
Nakonde
Shiwang'andu
Select All
Agreements
Committed to Timely Delivery
(Required)
Yes
No
Accept Terms & Conditions
(Required)
Yes
No
Capacity to use the MOA ZIAMIS
(Required)
Yes
No
I confirm that I possess the documents for which I have indicated 'Yes' in the application. I further agree to upload the required documents to ZIAMIS when requested(Required)
(Required)
Yes
No
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