ACCOUNT OPENING FORM - INDIVIDUAL

This form should be compleated in CAPITAL LETTERS. Characters and marks should be similar in style to the following

Customer Type: (Tick as appropriate)

Joint Account Fixed Investment Account Salary Account Other Types of Account

Account Type: (Tick as appropriate)

Current Accounts: Polaris Current Polaris Select

Savings Accounts: Polaris SavePlus PolarisWise Target Savings Polaris Senior Savings

Polaris Pearl Current Account Polaris Pearl Savings Account

Fixed Deposit: Fixed Investment (N500,000 and above)

Domiciliary Accounts:
Branch
Account No. (For official use only)

Bank Verification ID No. BVN

1. PERSONAL INFORMATION

Title Surname

First Name Middle Name

Marital Status (Please tick as appropriate) Single Married Others (please specify) Gender M F

Country of Birth Date of Birth

Mother’s Maiden Name

Nationality (for non Nigerian) Resident Permit No.

Permit Issue Date Permit Expiry Date

L.G.A State of Origin

Religion

Tax Identification Number (TIN) (if available)

Purpose of Account

2. CONTACT DETAILS

Residential Address

House Number Street Name

Nearest Bus Stop/Landmark

City/Town Local Govt. Area

State Country

Primary Secondary
Mobile No. Mobile No.

Mailing Address P. O. Box

Email Address

3. EMPLOYMENT DETAILS

Employment Status: Employed Self Employed Unemployed Retired Student NYSC Others
(specify)

Salary: Yes No Date of Employment (if employed)

(Expected) Monthly Income

(a) Less than N50,000 (b) N51,000 - N250,000 (c) N251,000 - N750,000 (d) Above N750,000

The Bank will not be liable for any loss arising from cash given to unauthorized staff or persons
 Business/Employer’s Name

Employer’s/Employment Address

House Number Street Name

Nearest Bus Stop/Landmark

City/Town Local Govt. Area

State Office Phone Number

Nature of Business/
Occupation

4. VALID MEANS OF IDENTIFICATION

National ID Card National Driver’s License International Passport INEC Voters Card *Others, please specify

ID No. ID Issue Date ID Expiry Date

National Identification Number (NIN)

*People in peculiar circumstances - Artisans, Petty Traders, Students who may not have the prescribed IDs

5. ACCOUNT SERVICE(S) REQUIRED (Please tick applicable option below)

Card Preferences: Naira Debit Card Dollar Debit Card (For domiciliary account)

Electronic Banking Preferences: Internet Banking Mobile Banking ATM POS Other Electronic Channels (Fees may apply) Specify

Transaction Alert Preferences: Email Alert (free) SMS Alert (Fees Apply)

Statement Preferences: Email Collection at Branch Statement Frequency: Monthly Quarterly Semi-Annually Annually

Cheque Book Requisition:

Cheque Confirmation Policy: To ensure the safety of your funds at Polaris Bank Ltd. We recommend you confirm cheques of N250,000 and above before such
cheques are presented over the counter or via clearing, cheques below N250,000 will be paid without prior confirmation.

Preferred Language of COmmunication: English Hausa Igbo Yoruba Others (state)

Authorized Signatory Authorized Signatory

6. DETAILS OF NEXT OF KIN

Surname Middle Name

First Name

Date of Birth Gender M F Title (specify)

Relationship

Primary Mobile No. Secondary Mobile No.

Email Address (optional)

Contact Details

House Number Street Name

Nearest Bus Stop/Landmark

City/Town Local Govt. Area

State Country

7. ACCOUNT MANDATE

a. Account Name:

b. Account Number: (for official use only)

c. Mandate authorisation/combination rule (Please tick as appropirate): Sole Signatory Either to Sign Both to Sign

d. Signatory:
Surname First Name

Other Name Class of Signatory

Affix
Identification Type
Passport
Photograph
Identification Number heare

Signature Date
8. ACCOUNT HELD WITH OTHER BANKS:

NAME AND ADDRESS OF STATUS:

S/N ACCOUNT NAME ACCOUNT NUMBER
BANK/BRANCH ACTIVE/DORMANT

9. INDIVIDUAL ACCOUNT MANDATE

10. TERMS AND CONDITION

 11. DECLARATION/INDEMNITY:

I/We hereby apply for the opening of accounts with Polaris Bank Ltd. I/We understand that the information given herein and the document supplied
are the basis for opening such account (s) and I/We therefore warrant that such information is correct. I/We further undertake to indemnify Polaris Bank
for any loss suffered as a result of any false information or error in the information provided to the Bank.

I/We hereby agree to indemnify Polaris Bank Ltd in full against any action, claim, proceeding loss, expense or damages ariging from the account or,
representations made by me/us in respect of this account or for whatsoever in connection with this account. I/We further confirm that all my/our dealings
in respect of this account shall not be contrary to any subsisting law or regulation in force whether in Nigeria or any oother country.

1. Name................................................................................ Signature (over stamp).................................................... Date ...........................

1. Name................................................................................ Signature (over stamp).................................................... Date ...........................

12. FATCA Requirements - For US Citizens and Residents only

Passport/Alien Number

Last Four (4) Digits of Social Security Number

Passport Issue Date Passport Expiry Date

13. PRIVACY POLICY

Kindly note that by completing the form, you are giving the Bank your consent to process and store your personal data in compliance with the Nigerian Data Protection
Regulation and you have the right to withdraw your consent at will. In addition, please be informed that the Bank will protect your data against unauthorized access. For
details, do refer to the Bank's privacy policy on: https://www.polarisbanklimited.com/privacy-policy/

FOR BANK USE ONLY

14. REQUIREMENT CHECKLIST

Savings Account

S/N DOCUMENTS REQUIRED CHECKED DEFERRED WAIVED

9. Two (2) independent and satisfied references (Fixed/Current/Domicilliary/Fixed Investment/Other Types of Account)

10. Resident permit (for non-Nigerian) Fixed/Current/Domicilliary/Fixed Investment/Other Types of Account

11. Other document provided (Fixed/Current/Domicilliary/Fixed Investment/Other Types of Account)

15. 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 Regulations, 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 High Risk

16. AUTHENTICATION FOR POLITICALLY EXPOSED PERSONS

Is the Applicant a Politically Exposed Person? Yes No

For Bank Use Only

17. ACCOUNT OPENED/AUTHORIZED BY

Customer Service Officer

Signature DATE

BSM

Signature DATE

18. ADDRESS VERIFICATION CARRIED BY:

Name

DATE
Signature

COMMENT(S) (Address description and result finding):

19. ACCOUNT OPENING AUTHORIZED / APPROVED BY

BDM

Signature DATE