ACCOUNT OPENING FORM - INDIVIDUAL
This form should be compleated in CAPITAL LETTERS. Characters and marks should be similar in style to the following
Customer Type: (Tick as appropriate)
Joint Account Fixed Investment Account Salary Account Other Types of Account
Account Type: (Tick as appropriate)
Current Accounts: Polaris Current Polaris Select
Savings Accounts: Polaris SavePlus PolarisWise Target Savings Polaris Senior Savings
Polaris Pearl Current Account Polaris Pearl Savings Account
Fixed Deposit: Fixed Investment (N500,000 and above)
Domiciliary Accounts:
Branch
Account No. (For official use only)
Bank Verification ID No. BVN
1. PERSONAL INFORMATION
Title Surname
First Name Middle Name
Marital Status (Please tick as appropriate) Single Married Others (please specify) Gender M F
Country of Birth Date of Birth
Mother’s Maiden Name
Nationality (for non Nigerian) Resident Permit No.
Permit Issue Date Permit Expiry Date
L.G.A State of Origin
Religion
Tax Identification Number (TIN) (if available)
Purpose of Account
2. CONTACT DETAILS
Residential Address
House Number Street Name
Nearest Bus Stop/Landmark
City/Town Local Govt. Area
State Country
Primary Secondary
Mobile No. Mobile No.
Mailing Address P. O. Box
Email Address
3. EMPLOYMENT DETAILS
Employment Status: Employed Self Employed Unemployed Retired Student NYSC Others
(specify)
Salary: Yes No Date of Employment (if employed)
(Expected) Monthly Income
(a) Less than N50,000 (b) N51,000 - N250,000 (c) N251,000 - N750,000 (d) Above N750,000
The Bank will not be liable for any loss arising from cash given to unauthorized staff or persons
Business/Employer’s Name
Employer’s/Employment Address
House Number Street Name
Nearest Bus Stop/Landmark
City/Town Local Govt. Area
State Office Phone Number
Nature of Business/
Occupation
4. VALID MEANS OF IDENTIFICATION
National ID Card National Driver’s License International Passport INEC Voters Card *Others, please specify
ID No. ID Issue Date ID Expiry Date
National Identification Number (NIN)
*People in peculiar circumstances - Artisans, Petty Traders, Students who may not have the prescribed IDs
5. ACCOUNT SERVICE(S) REQUIRED (Please tick applicable option below)
Card Preferences: Naira Debit Card Dollar Debit Card (For domiciliary account)
Electronic Banking Preferences: Internet Banking Mobile Banking ATM POS Other Electronic Channels (Fees may apply) Specify
Transaction Alert Preferences: Email Alert (free) SMS Alert (Fees Apply)
Statement Preferences: Email Collection at Branch Statement Frequency: Monthly Quarterly Semi-Annually Annually
Cheque Book Requisition:
Cheque Confirmation Policy: To ensure the safety of your funds at Polaris Bank Ltd. We recommend you confirm cheques of N250,000 and above before such
cheques are presented over the counter or via clearing, cheques below N250,000 will be paid without prior confirmation.
Preferred Language of COmmunication: English Hausa Igbo Yoruba Others (state)
Authorized Signatory Authorized Signatory
6. DETAILS OF NEXT OF KIN
Surname Middle Name
First Name
Date of Birth Gender M F Title (specify)
Relationship
Primary Mobile No. Secondary Mobile No.
Email Address (optional)
Contact Details
House Number Street Name
Nearest Bus Stop/Landmark
City/Town Local Govt. Area
State Country
7. ACCOUNT MANDATE
a. Account Name:
b. Account Number: (for official use only)
c. Mandate authorisation/combination rule (Please tick as appropirate): Sole Signatory Either to Sign Both to Sign
d. Signatory:
Surname First Name
Other Name Class of Signatory
Affix
Identification Type
Passport
Photograph
Identification Number heare
Signature Date
8. ACCOUNT HELD WITH OTHER BANKS:
NAME AND ADDRESS OF STATUS:
S/N ACCOUNT NAME ACCOUNT NUMBER
BANK/BRANCH ACTIVE/DORMANT
9. INDIVIDUAL ACCOUNT MANDATE
10. TERMS AND CONDITION
11. DECLARATION/INDEMNITY:
I/We hereby apply for the opening of accounts with Polaris Bank Ltd. I/We understand that the information given herein and the document supplied
are the basis for opening such account (s) and I/We therefore warrant that such information is correct. I/We further undertake to indemnify Polaris Bank
for any loss suffered as a result of any false information or error in the information provided to the Bank.
I/We hereby agree to indemnify Polaris Bank Ltd in full against any action, claim, proceeding loss, expense or damages ariging from the account or,
representations made by me/us in respect of this account or for whatsoever in connection with this account. I/We further confirm that all my/our dealings
in respect of this account shall not be contrary to any subsisting law or regulation in force whether in Nigeria or any oother country.
1. Name................................................................................ Signature (over stamp).................................................... Date ...........................
1. Name................................................................................ Signature (over stamp).................................................... Date ...........................
12. FATCA Requirements - For US Citizens and Residents only
Passport/Alien Number
Last Four (4) Digits of Social Security Number
Passport Issue Date Passport Expiry Date
13. PRIVACY POLICY
Kindly note that by completing the form, you are giving the Bank your consent to process and store your personal data in compliance with the Nigerian Data Protection
Regulation and you have the right to withdraw your consent at will. In addition, please be informed that the Bank will protect your data against unauthorized access. For
details, do refer to the Bank's privacy policy on: https://www.polarisbanklimited.com/privacy-policy/
FOR BANK USE ONLY
14. REQUIREMENT CHECKLIST
Savings Account
S/N DOCUMENTS REQUIRED CHECKED DEFERRED WAIVED
9. Two (2) independent and satisfied references (Fixed/Current/Domicilliary/Fixed Investment/Other Types of Account)
10. Resident permit (for non-Nigerian) Fixed/Current/Domicilliary/Fixed Investment/Other Types of Account
11. Other document provided (Fixed/Current/Domicilliary/Fixed Investment/Other Types of Account)
15. AUTHENTICATION FOR FINANCIAL INCLUSION
I. Is the customer socially or financially disadvantaged? Yes No
II. If answer to the (i) above is Yes, state other documents obtained in line with the Bank’s policy on socially/financially disadvantaged customer in compliance with
Regulation 77(4) of AML/CFT Regulations, 2013.
III. Does the Customer enjoy tiered KYC requirements? Yes No
IV. If answer to question (iii) above is Yes, identify the customer risk category: Low Risk Medium Risk High Risk
16. AUTHENTICATION FOR POLITICALLY EXPOSED PERSONS
Is the Applicant a Politically Exposed Person? Yes No
For Bank Use Only
17. ACCOUNT OPENED/AUTHORIZED BY
Customer Service Officer
Signature DATE
BSM
Signature DATE
18. ADDRESS VERIFICATION CARRIED BY:
Name
DATE
Signature
COMMENT(S) (Address description and result finding):
19. ACCOUNT OPENING AUTHORIZED / APPROVED BY
BDM
Signature DATE
