GENERAL ACCOUNT INFORMATION GN BANK LIBERIA LTD

PERSONAL INDIVIDUAL ACCOUNT Affix Affix

(Please indicate the category and type of account to open by ticking the applicable box below) Passport Passport
Photograph Photograph
BRANCH Here Here

ACCOUNT TYPE (1) ACCOUNT TYPE (2)

PURPOSE OF ACCOUNT (1)

PURPOSE OF ACCOUNT (2)

Currency Type
USD LRD OTHERS
ACCOUNT NO (1) (FOR OFFICIAL USE ONLY)

Currency Type
ACCOUNT NO (2) (FOR OFFICIAL USE ONLY) USD LRD OTHERS

2. PERSONAL INFORMATION

Title Surname

First Name

Maiden Name
(if applicable)

Other Names

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

D D M M Y Y Y Y
Place Of Birth Date of Birth

Mother’s Maiden Name

Nationality Resident Permit No.

County of Origin Country of Residence

D D M M Y Y Y Y D D M M Y Y Y Y
Permit Issue Date Permit Expiry Date

Place of Issue Hometown

Profession/Occupation

NASCORP NO
3. CONTACT DETAILS

ResidentialAddress
In Liberia

City/Town Nearest Landmark

Proof of Address Mobile Number

(indicate type and
serial Number
Fixed Tel. No

Email Address

Mailing Address

4. VALID MEANS OF INDENTIFICATION

National Driver’s License Passport Voter’s ID National Health Insurance Card

Others ID Country of Issue

D D M M Y Y Y Y D D M M Y Y Y Y
ID No. ID Issue Date Exp. Date

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

Card Preferences ATM Card Master Card Visa Card Others (please specify)

Electronic Banking Preferences Internet Banknig Mobile Banking Other Internet Banknig Products

Transaction Alert Preferences Email Alert SMS Alert

Statement Preferences Email Post Collection at Branch

Statement Frequency Monthly Quarterly Simi-Annually Annually

Cheque Book Requisition Opened Cheque Crossed Cheque 25 Leaves 50 Leaves 100 Leaves

6. EMPLOYMENT DETAILS

Employed Self Employed Unemployed Retired Student Others (please specify)

D D M M Y Y Y Y
Length of Period with Current Employer

Salary /Expected Income

 Employer’s Name

Employer’s Address

City/Town County

Nature of Business

Nature of Business

Nature of Business/

Office Phnoe No. Mobile No.

Employer’s Email Address

7. DETAILS OF NEXT OF KIN (in case of emergency)

Title Gender F M

Surname

Middle Name

First Name

Relationship

Phone No. 1 Phone No. 2

Residential Address
Residential Address
District/County

8. ADDITIONAL DETAILS

Full Name of Beneficiary

Owner(s) of the Account

(if applicable)

9. EXPECTED ACCOUNT ACTIVITY

Sources of Funds to the Account 1.

2.

Level of Deposits (Amount) Frequency of Dopos-

Expected Monthly Income from other Frequency of Withdrawals

 Name of Associated Business(es) 1.
(if Applicable)

2.

Type of Associated Busi-

ness

Associated Business
Address

10. ACCOUNTS HELD WITH OTHER BANKS

S/N NAME AND ADDRESS ACCOUNT NAME ACCOUNT NUMBER

OF BANK/BRANCH

1
2
3
4
5

11. TERMS AND CONDITIONS

12. ACCOUNT OPENING MANDATE

Mandate authorization ( (Please tick appropriate) Sole Signatory Either to Sign Both to Sign

A) Signatory *

Name:
Surname
First Name
Other Name
Class of Signatory
Identification Type
Identification No
Telephone Number
Signature and Date

SIGNATORY

Name Signature
13. DECLARATION

I/We hereby apply for thee opening of account(s) with …………………… Bank. I understand that information given herein
and the documents 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 thee Bank for any loss suffered as a result of any false information or error in the in-
formation provided to the Bank.

DISCLOSURE TO CREDIT REFERENCE

The bank will obtain information about you from the CBL and other Commercial Banks to check status and identity.

Name: …………………………………………… Signature: ……………………………… Date: ………………………………..

Name: …………………………………………… Signature: ………………………………. Date: ………………………………

14. (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 ex-
plained to me by and Interpreter.

MARK OF CUSTOMER/ MARK OF INTERPRETER/

THUMBPRINT/SIGNATURE THUMBPRINT/SIGNATURE

DATE
D D M M Y Y Y Y

NAME & ADDRESS OF INTERPRETER

LANGUAGE OF INTERPRETATION