ACCOUNT OPENING FORM - INDIVIDUAL - Fidelity Bank
ACCOUNT OPENING FORM - INDIVIDUAL
FORM A TIER 3
Category of Account: (Tick as appropriate)
Joint Account Fixed Investment Account Other Types of Account
Account Type: (Tick as appropriate)
others
Current Account Fixed Deposit Account Savings Account Domicilliary Account
This form should be completed in CAPITAL LETTERS. Characters and marks should be similar in style to the following
BRANCH
ACCOUNT No. (for official use only)
BANK VERIFICATION NUMBER 1. PERSONAL INFORMATION
Title
Surname
First Name Marital Status Single
(Please Tick as appropriate)
Country of Birth
L.G.A
Married
Others
(please specify)
Other Name
Gender F
M
Date
DD
MM
YYYY
of Birth
Mother's Maiden Name
State of Origin
Nationality (for non Nigeria)
DD
Permit Issue Date Tax Identification Number (TIN) (If available)
Other TIN
Purpose of Account
MM
YYYY
Resident permit No
DD
MM
YYYY
Permit Expiry Date
Are you a tax Residence more than one country?
in
Yes
No
Country Code
Religion
(Optional)
2. CONTACT DETAILS Residential Address House Number
Nearest Bus Stop/Landmark City/Town
State
Mailing Address
Street Name
Local Govt. Area Country
Country Code
Phone Num (1)
Email Address
Country Code
Country Phone Num (2)
3. VALID MEANS OF IDENTIFICATION
National ID Card National Driver's License International Passport INEC Voters Card * Others (Please specify)
ID No.
DD
ID Issue Date
MM
Y Y Y Y ID Expiry Date D D
* People in peculiar circumstances - Artisans, Petty Traders, Students who may not have the prescribed IDs
MM
YYYY
4. ACCOUNT SERVICE(S) REQUIRED (Please tick your preferred products and service below)
CARDS (Charges Apply)
INTERNET BANKING
ALERTS
OTHERS
Visa Credit Card
Visa debit Card NGN Classic
Verve Debit Card NGN
Master card USD
Enquiry Only Soft Token
(Charges apply)
Transactions Hard Token
(Charges apply)
SMS Alert (Charges apply)
Email Alert
Statement Preference: Email Collection at Branch Statement Frequency: Monthly Quarterly
Cheque Book Requisition: (Fees apply) Opened Cheque Crossed Cheque 25 Leaves 50 Leaves
Cheque Confirmation: Will you like to pre-confirm your cheque? Yes
No
Cheque Confirmation Threshold: If the answer to the above is yes, please specify the threshold
Mobile Banking Email Statement Interactive Voice Response self Service Semi-Annually Annually 100 Leaves
Fidelity Bank Plc RC103022
5. EMPLOYMENT DETAILS (OPTIONAL)
Employment Status: Employed Self Employed Unemployed Date of Employment (if employed) D D M M Y Y Y Y
Retired
Student
Other
(Please specify)
Annual Salary/Estimated Annual Income
Annual Salary:
(a) Less than N50,000
(b) N51,000-N250,000
( ) N251,000-N500,000
(f) N5 million - Less than N10 million (g) N10 million - Less than N20 million
(d) N501,000-Less than N1million (h) above N20 million
(e) N1 million-Less than N5 million
Employer's Name Employer's/Employment Address
House Number
Street Name
Nearest Bus Stop/Landmark
City/Town
Local Govt Area
State Nature of Business/Occupation
Office Phone Number
Fax Number
6. DETAILS OF NEXT OF KIN Surname First Name
Other Name(s) Title (Specify)
Date of Birth D D M M Y Y Y Y Relationship
Country Code
Mobile Number 1
Country Code
Email Address
Contact Details House Number
Street Name
Nearest Bus Stop/LandMark City/Town
Local Govt. Area
State
Country
7. ADDITIONAL DETAILS Name of Beneficial Owner(s) (If any)
Mobile Number 2
Gender F
M
Spouse's Name (If applicable)
DD
MM
YYYY
Spouse's Date of Birth
Sources of Fund to the Account
1
2 Expected Annual Income from Other Sources Name of Associated Business(es) (if any) 1
2
3 Type of Business Business Address
Spouse Occupation
Country
Fidelity Bank Plc RC103022
8. ACCOUNT HELD WITH OTHER BANKS:
NAME AND ADDRESS OF
STATUS:
S/N
BANK/BRANCH
ACCOUNT NAME
ACCOUNT NUMBER
ACTIVE/DORMANT
1 2 3 4
9. ACCOUNT MANDATE
(Please tick as appropriate)
a. Category of Account:
Joint Account Account Type:
Fixed Investment Account Other Types of Account
Current Account Fixed Deposit Account Savings Account Domicilliary Account
b. Account Name
c. Account No.
(for official use only)
d. Mandate authorisation/Combination rule (Please tick as appropriate): Sole Signatory
e. Signatory I Surname
First Name
Other Names
Either to sign
Both to sign
Class of Signatory:
I Identification Type:
Identification No:
I Telephone Number:
Signature & Date:
f. Signatory II Surname Other Names Class of Signatory:
Identification No:
First Name
I Identification Type: I Telephone Number:
Signature & Date:
10. POWER OF ATTORNEY Attorney-in-fact/Agent's details Surname
First Name
Nationality
Country Code Address House Number
Mobile Number 1
City/Town
State
Other Name(s) Title (Specify)
Country Code Street Name Local Govt. Area
Country
Mobile Number 2
Gender F
M
Fidelity Bank Plc RC103022
11. DECLARATION
I/We hereby apply for the opening of account (s) with Fidelity Bank Plc. I/We understand that the information given herein and the document supplied are the basis for the opening of such account (s) and I/We therefore warrant that such information is correct. I/We have read and understood the bank's account opening terms and conditions. I/We accept and agree to be bound by the said terms and conditions including those excluding/limiting the bank's liabilities. I/We agree that the bank may debit my account for service charges as applicable from time to time. I/We further undertake to indemnify the Bank for any loss suffered as a result of any false information or error in the information provided to the Bank.
1. Name...................................................................................................................... Signature............................................................... Date.................................................................
2. Name...................................................................................................................... Signature............................................................... Date................................................................. 12. JURAT (THIS SHOULD BE ADOPTED WHERE THE APPLICANT IS NOT LITERATE OR IS BLIND AND THE FORM IS READ TO HIM OR HER BY A THIRD PARTY) I agree to abide by the content of this agreement and acknowledge that it has been truly and audibly read over and explained to me by an Interpreter
MARK OF CUSTOMER/ THUMBPRINT
DATE:
DD
MM
YYYY
MAGISTRATE/ COMMISSIONER FOR OATHS
NAME OF INTERPRETER:
TEL. NO:
LANGUAGE OF INTERPRETATION:
13
I/We,................................................................................................. with account number..................................................... hereby pledge that I/We will not issue my/our cheque against unfunded account. Thank you.
Authorized Signatory
Authorized Signatory
Please note that the Economic and Financial Crimes Commission (EFCC) has directed Banks to periodically send the account details of customers that do not comply for investigation and prosecution.
1. REQUIREMENT CHECKLIST
Savings Account
FOR BANK USE ONLY
S/N DOCUMENTS REQUIRED
CHECKED DEFERRED WAIVED
1 Duly completed Account Opening Form
2 Specimen signature card duly completed
3 Recent passport photograph
4 Proof of Identity: International passport, Driver's license, National ID card, Valid Nigeria Voters Card (original must be sighted)
5 Resident Permit (for non-Nigeria)
6 Proof of Address: Utility bills, etc (Certified true copy is acceptable if original is not held)
7 Letter from Employer / School / NYSC (for salary account and or Student only)
8 Form W-8, W-9 and other FATCA documents
9 Valid and effective waiver
Fixed / Current / Domiciliary / Fixed Investment / Other Types of Account
S/N DOCUMENTS REQUIRED 1 Duly completed Account Opening Form 2 Specimen signature card duly completed
3 Two (2) recent passport photographs 4 Two (2) independent and satisfactory references 5 Proof of Identity: International passport, Driver's license, National ID card, INEC Voters Card
(original must be sighted) 6 Proof of Address: Utility bills, etc (Certified true copy is acceptable if original is not held) 7 Letter from Employer (for salary account only) 8 Resident permit (for non-Nigeria) 9 Other document Provided 10 Form W-8, W-9 and/other FATCA documents 11 Valid and effective waiver
CHECKED DEFERRED WAIVED
Fidelity Bank Plc RC103022
2. AUTHENTICATION FOR FINANCIAL INCLUSION
I. Is the customer socially or financially disadvantaged? YES
NO
ii. If answer to the (i) above is yes, state other documents obtained in line with the bank's policy on socially / financially disadvantaged customer in compliance with Regulation 77(4) of AML/CFT Regulation, 2013
iii. Does the customer enjoy tiered KYC requirements?
YES
NO
iv. If answer to question (iii) above is yes, identify the customer risk category:
Low Risk Medium Risk
3. AUTHENTICATION FOR POLITICALLY EXPOSED PERSONS
Is the Applicant a Politically Exposed Person? YES
NO
High Risk
For Bank Use Only: A. ACCOUNT OPENED BY:
Name
Signature:
Date:
DD
MM
YYYY
Name
Signature:
Date:
DD
MM
YYYY
B. DEFERRAL/WAIVER OF DOCUMENT (IF ANY) AUTHORISED BY:
Name Signature: Name
DD
Date:
MM
YYYY
Signature: C. ADDRESS VERIFICATION CARRIED OUT BY
Name Signature:
Name Signature: COMMENT(S)(Address description and result finding):
DD
Date:
MM
YYYY
DD
Date:
MM
YYYY
DD
Date:
MM
YYYY
D. ACCOUNT OPENING AUTHORIZED/APPROVED BY: Name Signature: Name
Signature:
Date:
DD
MM
YYYY
DD
Date:
MM
YYYY
Fidelity Bank Plc RC103022
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