Africa Prudential

E-DIVIDEND MANDATE FORM

SHAREHOLDERS ACCOUNT INFORMATION

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

Date must follow: DD/MM/YYYY format

Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }

Recent Passport Photograph (Maximum size 300kb)

{ binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }

Upload Signature (Maximum size 300kb)

{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }

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

{ binding firstError.message }

BANK DETAILS

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

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 firstError.message }

This service costs N150 per form exclusive of VAT.

Africa Prudential

E-DIVIDEND MANDATE FORM

SHAREHOLDERS ACCOUNT INFORMATION

Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
 IF Company (Name) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Residential Address (Not P.O.BOX) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address Line 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Shareholder's Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name of Stockbroking Firm {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Clearing House Number (CHN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Mobile Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Alternative Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Recent Passport Photograph {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Upload Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Valid ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
{ binding firstError.message }

BANK DETAILS

Bank Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other Banks Not Listed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Bank Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Bank Verification Number (BVN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Age of Bank Account {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please select the company(ies) where you have shareholdings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Other Companies Not Listed Above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
DECLARATION {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
NOTE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
The email has been sent.

Your progress has been saved.

{ binding firstError.message }
Africa Prudential

E-DIVIDEND MANDATE FORM

SHAREHOLDERS ACCOUNT INFORMATION

Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
 IF Company (Name) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Residential Address (Not P.O.BOX) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address Line 2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Shareholder's Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Name of Stockbroking Firm {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Clearing House Number (CHN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Mobile Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Alternative Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Recent Passport Photograph {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Upload Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Valid ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
{ binding firstError.message }

BANK DETAILS

Bank Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other Banks Not Listed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Bank Account Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Bank Verification Number (BVN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Age of Bank Account {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Please select the company(ies) where you have shareholdings {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Other Companies Not Listed Above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
DECLARATION {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
NOTE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }