E-PRODUCT APPLICATION FORMRC 575

Customer’s Name

Residential Address

Personal Information

State of Origin Date of BirthD D M M Y Y Y Y

Nationality

E-mail Address

Sex: Male Female Marital Status: Married Single Divorced Widowed

Telephone Mobile

Account Details

Current Account

Savings Account

Wema Treasure Account

Prestige Current Account

Other

Account No.

Account No.

Account No.

Account No.

Account No.

Branch

Branch

Branch

Branch

Branch

Product Offering (Please tick as applicable)

Internet Banking

Card type: Verve Card

Mobile Banking

MasterCard (Debit)

SMS Alert

MasterCard (Credit)

E-mail Alert MasterCard (Prepaid)

Visa (Debit) Visa (Credit)

Corporate Account ONLY

Company’s Name

Residential Address

Name of Requesting Officer

Primary Account No. Secondary Account No.

Preferred Name on ID

Declaration

I/We have read the terms and conditions governing the operation on the reverse side of this form and I/we accept the said terms and conditions

Authorised Signatory Authorised Signatory

Date D D M M Y Y Y Y

FOR OFFICIAL USE ONLY

CTSL’s Signature

CTSL’s Name

BSM’s Signature & Date

BSM’s Name

Date D D M M Y Y Y YD D M M Y Y Y Y

Date