E-Data Update Form.

PERSONAL INFORMATION

* Surname/Company’s Name

* Other Names

Gender:

MaleFemale

Date of Birth

Phone Number 1

Phone Number 2

Email Address

Alternate Email Address

Address

Old Address ( If Any)

Nationality

Occupation

Next of Kin Name

Next of Kin Relationship

Next of Kin Phone Number

Bank Verification Number (BVN)

Bank Name

Bank Account Number

CSCS Clearing House Number (CHN)

Name of Stockbroking Firm

DECLARATION

I/We hereby declare that the information I have provided is true and correct and that I shall be held personally liable for any of my personal details.

I/We also agree and consent that Cordros Registrars Limited may collect, use, disclose, process and deal in any manner whatsoever with my/our personal, biometric and shareholding informations out in this form and/or otherwise provided by me/us or possessed by Afriprud for administration of my/our shareholding and matters related thereto.

CORDROS REGISTRARS LIMITED
21, Norman Williams Street, Ikoyi, P.O. Box 75590 Victoria Island, Lagos, Nigeria.
E: [email protected] M: 07002673767 W: www.cordros.com

Please list the company(ies) where you have shareholdings

Company NameShare Holder Number

Signature Section

Name

Date

Signature

Name (Joint/ Company Signatories)

Date

Signature

Company Seal (if applicable)