E-DIVIDEND MANDATE FORM

SHAREHOLDERS ACCOUNT INFORMATION

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

IF Company (Name) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Residential Address (Not P.O.BOX) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address Line 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date must follow: DD/MM/YYYY format

Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Shareholder's Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Name of Stockbroking Firm {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Clearing House Number (CHN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Mobile Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Alternative Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Recent Passport Photograph {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Recent Passport Photograph (Maximum size 300kb)

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Upload Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Upload Signature (Maximum size 300kb)

Valid ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Valid ID Card (National identity card, Driver’s license, International passport, Voter’s card, etc)

BANK DETAILS

Other Banks Not Listed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Bank Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Bank Verification Number (BVN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please select the company(ies) where you have shareholdings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Other Companies Not Listed Above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

DECLARATION {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

By submitting this form I agree to the Privacy Policy and Terms Of Use of Africa Prudential Plc

NOTE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

This service costs N150 per form exclusive of VAT.

E-DIVIDEND MANDATE FORM

SHAREHOLDERS ACCOUNT INFORMATION

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

IF Company (Name) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Residential Address (Not P.O.BOX) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address Line 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Shareholder's Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name of Stockbroking Firm {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Clearing House Number (CHN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Alternative Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Recent Passport Photograph {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Upload Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Valid ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

BANK DETAILS

Other Banks Not Listed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bank Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bank Verification Number (BVN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please select the company(ies) where you have shareholdings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other Companies Not Listed Above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

DECLARATION {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

NOTE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

The email has been sent.

Your progress has been saved.

Copy your form link:

Email me my link:

{ binding firstError.message }

E-DIVIDEND MANDATE FORM

SHAREHOLDERS ACCOUNT INFORMATION

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

IF Company (Name) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Residential Address (Not P.O.BOX) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address Line 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Shareholder's Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name of Stockbroking Firm {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Clearing House Number (CHN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mobile Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Alternative Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Recent Passport Photograph {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Upload Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Valid ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

BANK DETAILS

Other Banks Not Listed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bank Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Bank Verification Number (BVN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please select the company(ies) where you have shareholdings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other Companies Not Listed Above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

DECLARATION {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

NOTE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}