Customer Request Form

PERSONAL INFORMATION (PLEASE USE CAPITAL LETTERS)

BVN No: Account No: 1805481317 Date:
22749208178 D D M M Y Y Y Y
Mobile No: + 2 3 4 9 1 1 4 1 5 4 Whatsapp
1 1 8 No: 9 1 1 4 1 5 4 1 1 8 0 3 1 1 2 0 2 4
FOR INDIVIDUAL ONLY:
Title: MR/MRS/MISS/DR/CHIEF/PROF: Mr Surname: K u t e r e

First Name: H a m m e d Middle Name: A b r a h a m

FOR ENTERPRISE/SOLE PROPRIETOR ONLY:

Business Name:

BN: TIN:
PLEASE TICK YOUR REQUEST TYPE:
D D M M Y Y Y Y D D M M Y Y Y Y
Account Statement Request: From Date: To Date:
Old Account Class New Account Class
Account Migration Request:
Documentation Submitted?
Reference/Confirmation/ Address Letter to:
Non-Indebtedness Letter:
Failed Transaction:

PND Lift SMS deactivation SMS activation Collapse ID

D D M M Y Y Y Y
Transaction Date Transaction Amount

POS ATM MOBILE WEB USSD

Reason for Account Closure: Move Balance to Existing Account:
Account Closure Request

:Card Issuance/ Visa Card MasterCard Verve Card Mobile Pin Activation/Modification
Mobile App:
PIN Activation PIN Reset: Enable Profile: Phone Unlock: Token Activation

ACCOUNT INFORMATION UPDATE (for update on existing data with the bank, tick as appropriate)
BVN Update/correction Customer Information Update Reactivation

Reason for Change: Marriage Others: SEX: Male Female

For Address Change
New Address:

For Change of Phone no:

D D M M Y Y Y Y
New Phone Number: Update of Date of Birth:
For Change of E-mail:
New E-mail:
For Change of Name:
Title: MR/MRS/MISS/DR/CHIEF/PROF: Surname:

First Name: Middle Name:

Certification:

I, ................................................................................................................................ certify that the information provided by me above are true and correct and here
by authorize the update.
Other remark(s):

Authorized Signatory/Date Authorized Signatory/Date

FOR OFFICIAL USE ONLY

Customer Care Officer: Signature Date
D D M M Y Y Y Y

Head of Operations: Signature Date

D D M M Y Y Y Y

Account officer/Branch Manager: Signature Date

D D M M Y Y Y Y

*Kindly provide valid means of identification and utility bill in addition to this form
Customer Compliance Form
PERSONAL INFORMATION (PLEASE USE CAPITAL LETTERS)

Title: MR/MRS/MISS/DR/CHIEF/PROF: Surname:

First Name: Middle Name:

Mother’s D D M M Y Y Y Y
maiden Name: Sex: Male Female Date of Birth:

Residential
Address:

Postal Address:

Phone (Home): Phone (Office):

Mobile No: Nationality:

E-mail Address:

Occupation: Employer’s name:

Employer's
Address:

Form of
Identification: National I.D. Card International Passport Driver's License Proxy
Identification No. Place of Issuance Expire Date
D D M M Y Y Y Y

FOR FOREIGNERS ONLY

D D M M Y Y Y Y D D M M Y Y Y Y
Visa Number Visa Valid From
Date of Arrival Date of Departure

Visa Valid Till Passport Number Passport Issue Date Passport Expiry Date Resident Permit Number

CERTIFICATION

I certify that the above particulars are true and correct.

Customer's Signature & Date

FOR OFFICIAL USE ONLY

Name Signature Date