Customer Information Form Individual

Customer Information Form Individual
Dear Client,

Real Estate Dealers are required by law to collect and maintain your most current information. You are therefore asked to complete and return this form so that your records can be updated accordingly.
Title

MrMrsMiss
Name*

First NameMiddle NameSurname
Other Names (including aliases)
Mother's Maiden Name*
Date of Birth*

MonthDayYear
Date
Place of Birth*
Nationality*
Home Address*
Mailing Address (if different from home address)
Telephone Numbers
Mobile*
Home
Work
Email Address*
example@example.com
Occupation (‘businessman/ businesswoman or self-employed’ is not acceptable)*
Nature of Business (if self- employed)
Name of Employer/ Business *
Address of Employer/Business*
Telephone Numbers (Business)
Fax
Work
Tax Registration Number (TRN)
Identification Type*
ID Number*
Expiration Date*

MonthDayYear
Date
Oops! Your ID has expired. Please enter a valid ID
Source of Funds
Have you or any relative or close associate been entrusted with prominent public functions (e.g. Member of Parliament, Senate or Mayor, Senior Government Official, Judiciary, Security Forces)*

YesNo
If Yes, state the type of public office
Address of Public Office
If Yes to the above give the name and address of spouse and children
*Spouse includes common law husband or wife
Name of Spouse
Address of Spouse
Name of Child 1
Address of Child 1
Name of Child 2
Address of Child 2
Name of Child 3
Address of Child 3
Client’s Signature*

Clear
Date*

MonthDayYear
Date
Are you completing this form on someone's behalf ?

YesNo
**this section is only applicable if an agent is completing the form on behalf of the client
Power of Attorney or a letter duly notarised (where application is submitted by an agent)

Cancelof
Name

Agent’s First NameAgent’s Middle NameAgent’s Last Name
Agent’s Address
Date of Birth

MonthDayYear
Date
Nationality
Identification Type & Number: (DL, PP, Nat ID, Other) state
Tax Registration Number
I declare that the information given above is correct to the best of my knowledge and belief and any misrepresentation can void the application.
Agent’s Signature

Clear
Date

MonthDayYear
Date
I declare that the information given above has been verified by original documents and or certified copy (ies) where applicable, to ensure the veracity of the information given
CSR Date

MonthDayYear
Date
NB: The following documents are required for processing of your transaction
- Power of Attorney or a letter duly notarised (where application is submitted by an agent).
- Proof of Address
- Picture identification (customer and agent, where applicable)
- TRN (if a driver’s licence is not being used)
Tag

Real Estate - SellerReal Estate - PurchaserReal Estate - LandlordReal Estate - Tenantcashbankloannhtloanjfm
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Customer Information Form Individual

Dear Client,

Telephone Numbers

Telephone Numbers (Business)