Customer Information Form (Individual)

Customer Information Form Individual

Dear Customer,

We are required by law to collect and maintain your most current information. We therefore ask that you complete and return this form so that your records can be updated accordingly.

Section A

Surname:

First Name:

Middle Name:

Other Names (including aliases):

Mother's Maiden Name:

Title: Mr. Mrs. Miss

Date of Birth:

Place of Birth:

Nationality:

Home Address:

Mailing Address (if different from home address):

Telephone Numbers:

Home:

Mobile:

Work:

Email Address:

Occupation (‘businessman/businesswoman or self-employed’ is not acceptable):

Nature of Business (if self-employed):

Name of Employer/ Business:

Address of Employer/Business:

Telephone Numbers:

Fax:

Work:

Identification Type: (DL, PP, Nat ID, Other)

ID Number:

Expiration Date:

Source of Funds:

Tax Registration Number (if driver's license is not being used):

Section B

Have you or any relative or close associate been entrusted with prominent public functions (e.g. Member of Parliament, Senate or Mayor, Senior Government Official, Judiciary, Security Forces) Yes No If Yes, state the type of public office:

Address:

If Yes to the above give the name and address of spouse and children

Name of Spouse*

Address of Spouse

Name of Child

Address of Child

Name of Child

Address of Child

Name of Child

Address of Child

*Spouse includes common law husband or wife

Client's Signature X

Date

**this section is only applicable if an agent is completing the form on behalf of the client

Please draw your signature before submitting.

Section C

I declare that the information given above has been verified by original documents to ensure the veracity of the information given

Signature of CSR/Compliance

Date

NB: The following documents are require for processing of your transaction

Power of Attorney or a letter duly notarised (where application submitted by an agent).
Proof of Address
Picture identification (customer and agent, where applicable)
TRN (if a driver's licence is not being used)