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Application Form for GTA plc Business Partner by oqp13905

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Application Form for GTA plc Business Partner
Please fill in all required details in Block Letters               Application No:

Please                as appropriate                               Date of Application

*Field mark with asterix is mandatory.




     A.   PERSONAL DETAILS

     1.   First Name (Mr/Mrs/Ms)*




     2.   Last Name (Mr/Mrs/Ms)*




     3.   Represented by (Mr/Mrs/Ms)*




     4.   Occupation




     5. Sex*                                                       Male                           Female




     6.   Date of Birth*                                     D     D M M        Y        Y    Y     Y




     7.   Educational Qualifications*            SSCE/WAEC   OND          GRADUATE           POSTGRADUATE (Specify……….……)




     8.   Professional Insurance Qualifications (if any)
Application Form for GTA plc Business Partner


   9.   Residential Address*




                                     City




                                     State




   10. Telephone*                   Mobile




                                    Home




                                   Office




   11. E-mail    Address 1




   12. E-mail    Address 2




                                                Page 2 of 7
Application Form for GTA plc Business Partner




   B.   BUSINESS DETAILS

   1.   Name of Organisation




   2.   Business/Correspondence Address




                                                City




                                                State




     4. Do you have an independent office?                      Yes                 No




   3.   In the last 10 years, have you:

        •    Been convicted of an offence                                                                Yes    No

        •    Been the subject of proceedings now pending that may lead to a conviction of an offence Yes        No

        •    Had a judgment, including findings in relation to fraud, misrepresentation or dishonesty

             given against you in any arrangement with your creditors                                   Yes     No

        •    Been an insolvent, bankrupt or entered into any arrangement with your creditors            Yes    No




   4.   if yes to any of the questions above, please give details:

        ________________________________________________________________________________________________

        ________________________________________________________________________________________________


                                                            Page 3 of 7
Application Form for GTA plc Business Partner




3.Please give details of any other club/organization/society membership held ________________________________

                                                                                               _________________________________




4.   Why do you want to join GTA as a Business Partner?




5.   Do you have a GTBank bank account?                                    Yes            No

     If Yes, specify branch and account number

                                           Account Number




                                                      Branch

Commissions due to you will be credited directly into your GTBank account. If you do not have an account with GTBank, account opening forms
will be provided for you.




6.   A copy of either of the following forms must be attached to this application form upon submission:

          •     Bank statement for the last 3 months

          •     Company audited accounts for the previous year




7.   The following are infrastructure requirements for the Business Partner office. Please tick the items which you presently
     have available for use in a BP office.

                2
     •    30 m office space                                                      •    Telephone

     •    Computer with internet access and alternate                            •    Desk and chairs
          power supply
                                                                                 •     Air conditioning unit
     •    Printer
                                                                                 •    Scanner
     •    Power generator




                                                               Page 4 of 7
Application Form for GTA plc Business Partner


        REFERENCES

   1.   Please give two references*




   First Name




   Last Name




   Contact Address




   PHONE                                                      MOBILE




   EMAIL




   2.   Please give two references*




   First Name




   Last Name




   Contact Address




   PHONE                                                      MOBILE




   EMAIL




                                                Page 5 of 7
Application Form for GTA plc Business Partner


   References could be one of the following

        GTA Employee or Business Partner or Associates

        Government official

        Bank Manager

        Any other professional




   3.   Are you related to any employee of Guaranty Trust Assurance plc?

        If yes, please provide details _______________________________________________________




        I do hereby declare that the foregoing statements and answers are to be best of my knowledge and belief, true and
        complete and that shall be the basis of agreement between me and Guaranty Trust Assurance plc, and that if any of
        the foregoing answers or statements are untrue or incomplete the said Contract shall stand automatically terminated
        from the date on which such knowledge comes to the Company.

        I hereby confirm and undertake to provide any information regarding my individual/firm/organization profile and past
        experience/business/activities or any other related information to Guaranty Trust Assurance plc whenever required
        and will co-operate with any staff of Guaranty Trust Assurance plc or with any authorized agency for any such
        information verifications.

        I further hereby confirm that this Business Partner Application form has been completed by me in my own
        handwriting.




        Signature                                                          Stamp in case of partnership or company




        Signed by




        Date                                                                    Place




                                                      Page 6 of 7
Application Form for GTA plc Business Partner


FOR OFFICIAL USE




    Business Partner Office inspected by:




    Date:




    Assigned BP Manager




    Approved by




    Approved by




                                                Page 7 of 7

								
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