AGENT/MANAGER/PARTNER/DRIVER FORM

A. IDENTITY DETAILS

1. Name : FAYEMI IDOWU SUNDAY

2. a. Gender: Male b. Marital status: Married c. Date of birth:23/04/78

3. a. Nationality: NIGERIA
b. State of Origin: OYO

4. LGA_______________________________

5. a. NIN: __________________________________

6. Specify the proof of Identity submitted: YES

7. Asset Plate Number: LSD 500FS

8. Asset Category

VAN MINI -VAN BIKE

9. Driver license number: _____________________________________________________________

B. ADDRESS DETAILS

1. Residence Address: 23 ORE OFE BUSTOP, ILE IBADAN, IJEGUN IKOTUN

City/town/village: IJEGUN-IKOTUN Pin Code: State: LAGOS Country: NIGERIA

2. Contact Details: Tel. (Off.) Tel. (Res.) Mobile No.: 08033793238 Email id:

3. Specify the proof of address submitted for residence address:

4. Permanent Address

City/town/village: State: Country:

DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief
and I undertake to inform you of any changes therein, immediately. In case any of the above information is
found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

Signature of the Applicant

Date:
(dd/mm/yyyy)