Application Form for GTA plc Business Partners by andychukse

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Application Form for GTA plc Business Partners
Please fill in all required details in Block Letters Please Application No: Date of Appointment as appropriate

ü

*Field mark with asterix is mandatory.

A. 1.

PERSONAL DETAILS Name of the BP (Mr./Mrs./Ms)*

2.

Represented by (Mr/Mrs/Ms)*

3.

Spouse’s Name

4. Sex*

Male

Female

5.

Date of Birth*

D

D M M

Y

Y

Y

Y

6.

Educational Qualifications*

SSCE/WAEC

OND

GRADUATE

POSTGRADUATE (Specify……………)

7.

Professional Insurance Qualifications (if any)

8.

Residential Address*

City

State

9.

Telephone*

Mobile

Home

Office

10. E-mail

B.

DETAILS OF ALL YOUR BUSINESS OR THOSE OF YOUR FAMILY

§ Do you have an independent office?

Yes

No

C.

FAMILY BACKGROUND Age Relationship Profession

Name

1.

How many years have you/your family been in the area/town/city? <5 years 5 – 10 years 10 – 20 years 20 – 30 years >30 years

2a.
§ § §

In the last 10 years, have you:
Been convicted of an offence Been the subject of proceedings now pending that may lead to a conviction of an offence Had a judgment, including findings in relation to fraud, misrepresentation or dishonesty given against you in any arrangement with your creditors § Been an insolvent, bankrupt or entered into any arrangement with your creditors Yes Yes No No Yes Yes No No

2b.

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

3.

Please give details of any other club/organization/society membership held ________________________________ _________________________________ __________________________________

D. 1.

REFERENCE CHECK Please give two references (mandatory) Name & Address

SURNAME

FIRST NAME

OTHER NAMES

ADDRESS

PHONE

MOBILE

EMAIL

Name & Address

SURNAME

NAME

OTHER NAMES

ADDRESS

PHONE

MOBILE

EMAIL

References could be one of the following § § § § GTA Employee or Business Partner Government official Bank Manager Any other professional

2.

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


								
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