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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