Optimus Bank ACCOUNT OPENING FORM (Individual)

Branch Name of Account

Account type

Current Account Savings Account Fixed Deposit Account Joint Account

Domiciliary Account

$ USD € EUR ¥ CNY £ GBP Others

Account Tier

Tier 1 Tier 2 Tier 3

Regulatory limits apply to Tier 1 and Tier 2 accounts

Bank Verification Number (BVN)11 digits NIN11 digits

Title Surname First Name Middle Name

Marital Status

Single Married Others

Marital Status (specify)

Gender

Male Female

Date of Birth Place of Birth Mother's Maiden Name Tax Identification NumberIf applicable

Nationality

Nigerian Others

Nationality (specify) State of Origin L.G.A. of Origin Resident Permit No. Permit Issue Date Permit Expiry Date Purpose of Account Source of Fund / Wealth

Residential Address

House Number Street Name Nearest Bus Stop / Landmark City / Town L.G.A. State Country

Contact

Mobile No. 111 digits, starting with 0 Mobile No. 2 Email Address

Social Media Handles

Facebook Instagram X (Twitter) LinkedIn

Identification

Identification card

National ID Card National Driver's Licence International Passport Permanent INEC Voter's Card Others

Identification card (specify) ID No. ID Issue Date ID Expiry DateWhere applicable

Title Surname First Name Middle Name Date of Birth

Gender

Male Female

Relationship Email Residential Address Nearest Bus Stop / Landmark L.G.A. State Mobile No. 111 digits, starting with 0 Mobile No. 2

Social Media

Facebook Instagram X (Twitter) LinkedIn

Debit Card Preferences (fees apply)

Naira Debit Card Dollar Debit CardFor domiciliary account only

Online Banking

Mobile Banking Internet Banking

Transaction Notification

SMS AlertFees apply EmailFree

Statement Preferences

Email Alert Branch

E-Statement Frequency

Monthly Quarterly Bi-Annually

Cheque Book Requisition

None 50 Leaves 100 Leaves

Employment Status

Paid Employment Self Employed Unemployed Retired Student Others

Employment Status (specify) Employer's Name Date of Employment

Expected Annual Income

Less than ₦50,000 ₦50,000 – ₦250,000 ₦250,001 – ₦500,000 ₦500,001 – ₦1,000,000 ₦1,000,001 – Less than ₦5 Million ₦5 Million – Less than ₦10 Million ₦10 Million – Less than ₦20 Million ₦20 Million & Above

Office Address Nature of Business / Occupation

Signatory 1

Name Mobile No(s) Mandate Authorization and Combination Rule

Signatory 2

Name Mobile No(s) Mandate Authorization and Combination Rule

Declaration

I confirm the information provided is true and correct.

Date