Investor’s Data and Consent Form

INSTRUCTION

Please complete in capital letters.

SECTION A – INVESTOR’S DATA (PERSONAL)

Title Surname First Name Other Names

Maiden Name (if any): NIN: TIN:

Current Address:

City: State:

Post Code: Country:

Previous Address (if any):

City: State:

Post Code: Country:

Nationality: Gender: Male: [ ] Female: [ ] Date of Birth: DD/MM/YYYY

Phone Number 1: Phone Number 2:

E-mail Address:

Alternate E-mail Address:

Bank Verification Number (BVN):

Bank Name: Bank Branch:

Bank Account Number: Bank Account Opening Date: DD/MM/YYYY

SECTION B: NEXT OF KIN

Next of Kin Name:

Next of Kin Address:

City: State: Country:

Phone Number 1: Phone Number 2:

E-mail Address:

Alternate E-mail Address:

SECTION C – INVESTOR’S DATA (COMPANY/ FIRM) (Please tick appropriately)

Company’s Name:

RC Number: CAC Registration Date: DD/MM/YYYY TIN:

Current Address:

City: State:

Post Code: Country:

Previous Address (if any):

City: State:

Post Code: Country:

Phone Number 1: Phone Number 2:

E-mail Address:

Alternate E-mail Address:

Bank Name: Bank Branch:

Bank Account Number: Bank Account Opening Date: DD/MM/YYYY

Nature of Business:

Beneficial Ownership:

S/N	Name	Full Address
1.
2.
3.
4.

Source of Funds:

Directors/ Partners

S/N	Name	Address	BVN	NIN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

SECTION D – CAPITAL MARKET OPERATOR (CMO) DETAILS

Name of CMO:

Function(s):

Stockbroker’s Code (If any): Registrars’ ID No (If any):

CONSENT CLAUSE

I/We ___________________________ hereby give consent that my/our data may be processed by authorized entities such as Broker/Dealers, Fund/Portfolio Managers, Clearing Houses, Depositories, Registrars, Banks, Custodians, Nominees, Exchanges, Securities & Exchange Commission(SEC) and other authorized entities approved by SEC for the purpose of my/ our transactions in securities and other purposes directly related to it. I/ we further consent that my/our data can be shared between these entities for the purpose of performing the service. The proceeds of sale of my/ our investments and return on investments including dividend, interest, lease rentals and any other form of return on investments should be paid to the bank account disclosed in this form.