KYC REGISTRATION

Personal Details of Business Owner

Surname

First Name

Passport
Middle Name

Email:

Contact Phone Gender: M F Tick

Number appropriate

Single Widow Widower Tick

Date of Birth DD DD MM MM YY YY YY YY Marital Status: Married appropriate

Residential
Address

Country

State

LGA

Business Details

Business
Name

Business
Address

State LGA

Type of Sole Proprietorship Partnership

Business

BVN

Account
Name

Bank Name

Account
Number

ID Type Passport Driver’s License National ID Voter’s Card

Next of Kin:

First Name

Full Name

Middle Name

Relationship

Kin’s DOB

Gender

State

LGA

Phone Number

Kin’s I D Card Type

Kin’s Address

KYC Document Submitted

PASSPORT PHOTO UTILITY BILL I.D. CARD KIN’S I.D.

Declaration

* I hereby certify that the information provide in this form is true and accurate. I agree that appropriate measures
including legal actions could be taken against me if the information that I have provide here is discovered to be false*

Signature Date DD MM YY

For Official Use Only

Agent Checklist Approved by

Means of ID---------------------------- Name

Passport Photograph

Proof Address (Utility bill) Date DD MM YY Signature