Customer Request Form

PERSONAL INFORMATION (PLEASE USE CAPITAL LETTERS)

BVN No: 2 2 3 65 5 94 17 6 Account No: 0 68 95 1 1 93 4 Date:
D D M M Y Y Y Y
Mobile No: 0 7 0 3 84 51 3 1 6 Whatsapp No: 0 70 38 4 51 3 16 07 0 2 2 02 5
FOR INDIVIDUAL ONLY:
Title: MR/MRS/MISS/DR/CHIEF/PROF: Mr Surname: B OL A J I
First Name: O L U DA R E Middle Name:
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:

Account Migration Request: Old Account Class New Account Class

Documentation Submitted?
Reference/Confirmation/ Address Letter to:
Non-Indebtedness Letter:

PND Lift SMS deactivation SMS activation Collapse ID

Account Closure Request

Reason for Account Closure: Move Balance to Existing Account:

: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: O L U GB A R OA D I L O GB O OT A

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:

CARD TERMS & CONDITIONS ACKNOWLEDEMENT

Certification:
Bolaji Oludare
I, ................................................................................................................................ certify that the information provided by me above are true and correct and
subject to conditions attached to this form in respect of Debit card request, which I have read and understood, please effect the transaction detailed
above and here.
Other remark(s):

Authorized Signatory/Date Authorized Signatory/Date

31/01/2025 31/01/2025
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: MR Surname: B OL AJ I

First Name: O L UD A R E Middle Name:
Mother’s D D M M Y Y Y Y
maiden Name: A B OL A D E Sex: Male Female Date of Birth:
06 04 19 8 9
Residential O L U GB A R O A D, I L O GB O OT A OG U N S T.
Address:

Postal Address:

Phone (Home): Phone (Office):

Mobile No: 0 7 03 84 5 13 1 6 Nationality:

E-mail Address: B O L A J I o L U D A R E. D E S MO N D @ G M A I L. C O M

Occupation: P RE S S C R E W Employer’s name: B OL T I N T E RB I Z

Employer's L A GO 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
8 87 2 3 97 55 4 1 OGUN STATE

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

07/02/2025

FOR OFFICIAL USE ONLY

Name Signature Date

 Terms and Conditions for Card Request

Access Bank is authorized to issue Debit card(s) where I) To consent to the transmission of communication through
applicable for use at any Access Bank ATM or other Bank's ATM the Electronic Banking Channels and acknowledge that the
on the InterSwitch/ Visa/MasterCard network and other Electronic Banking Channels are not necessarily secure
electronic channels e.g. PoS terminals, Web and Mobile. The
communication and delivery system and understand the
card allows Cash Withdrawal, Balance Enquiry, Change of PIN
and any other services that may be added in the future at any confidentiality associated with same.
ATM terminal/website that accepts these transactions from
cardholders account. j) To indemnify and hold the Bank harmless from liability for any
loss or damage to me/us or the Bank that may be incurred
Furthermore, I/We agree arising from the use of the Electronic Banking Channels.
a) To ensure the safety of the Debit card(s) in my/our
Access Bank Plc has informed me/us that it is a member of
possession and not disclose the Personal Identification Number
Credit Bureau Agencies (CBA) licensed by the Central Bank of
(PIN) to any other party.
Nigeria (CBN) to create. organize and manage database for the
b) To formally notify the bank of the loss, theft or damage of the exchange and sharing of information on credit status and
card(s) and to provide all information in my/our possession history of individuals and businesses.
regarding such theft, loss or damage. I/We hereby agree that:

c) That my/our account should be debited for the cost of k) The Bank may collect, use and disclose any information
issuance of a new card/replacement of any lost, stolen or provided in the course of banker-customer relationship to CBA
damaged cards and transaction costs. and that the Credit Bureau may use the information for any
approved business purposes as may from time to time be
d) That the Bank is authorized to provide the police with any prescribed by the CBN and/or any relevant statute.
information it considers necessary and relevant in the event of
L) Information held about me/us by the CBA may be linked to
loss, misuse or theft of the card(s)
records relating to one or more of our partners(s)/directors(s)
and you may as a result be treated as financially linked and
e) That the bank reserves the right at any time to suspend or
my/our application will be assessed with reference to any
cancel the cardholders right to use the Debit card(s) entirely or
associated records. In addition, for any joint application made by
in respect to specific facilities or refuse to re-issue, renew or
me/us with any other person(s), new financial association may
replace the Debit card(s) without affecting any outstanding
be created at the CBA which will link our financial records.
obligation the cardholder may have under this agreement.
M) You are entitled to disclose information about any co-
f) That the Debit card(s) remains the property of Access Bank applicant or guarantor and/or anyone else referred to by you,
Plc at all times and upon request any or all Debit card(s) issued and to authorize us to search and/or record such information at
must be returned to Access Bank Plc within 48hours or to any CBA about me/us and as such co-applicant or guarantor or
person acting on behalf of Access Bank Plc. other person. I've understand that an association will be created
at the CBA, which will link our financial records. I/We hereby
g) That my/our card should be automatically renewed upon agree to indemnify and hold the bank harmless against all
expiry without further recourse to me/us. claims, costs, fees, expenses, damages and liabilities against the
Access Bank Plc is authorized to avail me/us banking services Bank relating to or arising as a result of, the disclosure of
through Electronic Banking Channels including but not limited information about such co-applicant or guarantor or other
to Internet Banking: SMS Banking and Telephone Banking and person or any use of such information by CBA in compliance
I/We agree with the following: with the provisions of any CBN guideline and/or relevant statute.

h) To accept that any activity performed on my/our account N) The Bank is hereby released and discharged from its
through the Electronic Banking Channels shall be deemed to obligations under the Bankers duty of secrecy and forswear
have been performed by me/us or my/our authorized my/our right to any claim, damages, loss etc on account of such
representatives or assignees and duly approved by the disclosure to CBA in accordance with the provisions of any CBN
authorized signatories to the account. Guideline and/or relevant statute.