CATEGORY OF BUSINESS
FundBrokersCustodianOthers
If Others, Specify
*BENEFICIARY OWNER DETAILS
Nominee Fund Name
*STATEMENT SERVICES
Mode of Statement DeliveryEmailBy postSMSCollection
Mode of Statement DeliveryQuarterlyYearlyMonthlyWeekly
*EXPECTED ACCOUNT ACTIVITY
Source of FundsMember ContributionProceeds from Businessothers
Initial Investment Amount
Anticipated Investment Activity: Top-upsMonthlyQuarterlyBi-AnnualAnnualOthers
WithdrawalsMonthlyQuarterlyBi-AnnualAnnualOthers
Anticipated Investment Amount
Regular Top-up Amount (expected)
Regular Withdrawal Amount (expected)
*KEY CONTACT PERSON
Surname
First Name
Other Names
Date of Birth
GenderMaleFemale
GenderResident GhanaianNon Resident GhanaianResident ForeignerNon Resident Foreigner
If counter of origin is not Ghana, please provide following
Resident Permit Number
Place of Issue
Date of Issue
Date of Expiration
ID TypeVotersDrivers LicenseSSNIT Biometric CardNational ID
Job Title
Email
Contact Number 1
Contact Number 2
*BENEFICIAL OWNERSHIP Beneficial Owner 1
PEP Status
Contact
Address
Ownership %
Beneficial Owner 2
*DIRECTORS Director 1
Director 2
*BANK ACCOUNT DETAILSBank 1
Bank Name
Bank Branch
Account Name
Account Number
Bank 2
*EMAIL/ PHONE/ FAX INDEMNITY
Email/ Telephone/ Fax Indemnity
DeclarationI/we hereby declare that all the information submitted by me/us in this form is correct, true and valid, that by my/our request, to open and maintain securities account(s) in my/our name and undertake to notify (Me and or my Company) of any changes to my/our particulars or information as may be necessary. I/We also declare that we have read thoroughly and understood the contents of this application and have given my/our consent by virtue of my/our signature(s) on this form. I/We consent that investment decisions are my/our prerogative without sole reliance on the investment advice received from (Me and or my Company). (Me and or my Company) accepts no liability for any direct or consequential loss arising from my/our decision. I/We also declare that all debits incurred on my/our securities account(s) by virtue of my/our trade orders shall be settled by me/us accordingly.
