Member KYC Form Please complete the online KYC form and we will get back to you! Date Form Submitted: Know Your Customer “KYC” Kindly Submit with Certified ID/ Omang Copy Please select your Membership / Beneficiary Group Member Individual Member Beneficiary Applicant/User’s Details Title, Name and Surname Trading Name / Stage Name: Nationality Date of Birth Omang / Passport Deceased Name Group Name Address and Contact Details Postal Address Address: City / Town / Village District Telephone Mobile Email Occupation Place of Work Banking Details Bank Name Branch Account Number Account Type Source of Funds Beneficiary Details (if changed) Full Names & Surname Mobile Relationship Declaration I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be liable for it. Full Names & Surname Date Place Signature Clause: Please Tick: By signing below, you agree that: (i)You have read, understood, and accept the above recorded terms (ii) All information you have provided is correct and complete (iii) You have authority to sign on behalf of the licensee Signature (Type your Name & Surname) Submit Form
