Customer Request Form
PERSONAL INFORMATION (PLEASE USE CAPITAL LETTERS)
BVN No: 2 2 3 7 0 8 2 5 7 2 2 Account No: 0 0 2 8 5 8 1 9 7 3 Date:
D D M M Y Y Y Y
Mobile No: 0 8 0 3 8 1 6 4 2 2 3 Whatsapp No: 0 8 0 3 8 1 6 4 2 2 3 2 7 0 1 2 0 2 5
FOR INDIVIDUAL ONLY:
Title: MR/MRS/MISS/DR/CHIEF/PROF: Surname: U m a r
First Name: I s h a q 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: 2 7 0 1 2 0 2 5 To Date:
Old Account Class New Account Class
Account Migration Request:
Access wallet tier 2 Premier savings Documentation Submitted?
Reference/Confirmation/ Address Letter to:
Non-Indebtedness Letter:
Failed Transaction:
PND Lift SMS deactivation SMS activation Collapse ID
D D M M Y Y Y Y
Transaction Date 2 6 0 1 2 0 2 5 Transaction Amount T h r e e h u n d r e d
POS ATM
t h o uMOBILE
s a n d n a iWEBr a USSD
Reason for Account Closure: Move Balance to Existing Account:
Account Closure Request
: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:
For Change of Phone no:
D
2 D
9 0M 9M 1 Y 9 Y 8 Y 9 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:
Certification:
I, ................................................................................................................................
Ishaq Umar certify that the information provided by me above are true and correct and here
by authorize the update.
Other remark(s):
27/01/2025
Authorized Signatory/Date Authorized Signatory/Date
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: Surname: U M A R
First Name: ISHAQ Middle Name:
Mother’s D D M M Y Y Y Y
maiden Name: FATIMA UMAR Sex: Male Female Date of Birth: 1 5 0 1 1 9 6 3
Residential N O 3 8 T Y A N K W A B A A R O G O
Address:
Postal Address:
Phone (Home): Phone (Office):
Mobile No: 0 8 0 3 8 1 6 4 2 2 3Nationality: N I G E R I A N
E-mail Address: i s h a q u m a r 0 1 2 3 @ g m a i l . c o m
Occupation: B U S I N E S S Employer’s name: S E L F
Employer'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
9 8 9 9 7 1 1 2 0 4 0 JOS
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
27/01/2025
FOR OFFICIAL USE ONLY
Name Signature Date
