SURNAME
FIRST NAME
OTHER NAME
ORGANIZATION
OFFICIAL ADDRESS
RESIDENTIAL ADDRESS
REG/FILE NO
IPPIS NO
PHONE NUMBER
E-MAIL
GENDER Choose one Male Female
MARITAL STATUS Choose one Single Married Divorced Widowed
HOUSE TYPE Choose one 1- Bed Room Block Of Flats 2- Bed Room Block Of Flats 3-Bed Room Block Of Flats 4-Bed Room Block Of Flats 2-Bed Room Terrace Duplex 3 Bed Room Terrace Duplex 4 Bed Room Terrace Duplex 2 Bed Room Twin Duplex + BQ 3 Bed Room Twin Duplex + BQ 4 Bed Room Twin Duplex + BQ 3 Bed Room Det Duplex + BQ 4 Bed Room Det Duplex + BQ 5 Bed Room Det Duplex + BQ 6 Bed Room Det. Duplex + BQ 7 Bed Room Det. Duplex + BQ
COST choose house type above
% EQUITY PAYMENT Choose one 30 25 20 15 10
BANK Choose one Access Bank Plc Citibank Nigeria Limited Diamond Bank Plc Ecobank Nigeria Plc Enterprise Bank Fidelity Bank Plc First Bank Nigeria Limited First City Monument Bank Plc Guaranty Trust Bank Plc Key Stone Bank MainStreet Bank Skye Bank Plc Stanbic IBTC Bank Ltd Standard Chartered Bank Nigeria Ltd Sterling Bank Plc SunTrust Bank Nigeria Limited Union Bank of Nigeria Plc United Bank For Africa Plc Unity Bank Plc Wema Bank Plc Zenith Bank Plc Heritage Banking Company Ltd
ACCOUNT NUMBER
ACCOUNT TYPE Choose one Savings Account Current Account Fixed Deposit Account Joint Account Domiciliary Account Corporate Account Non-resident Nigerian Account
NAME OF NEXT OF KIN
NEXT OF KIN ADDRESS
NEXT OF KIN PHONE No
NEXT OF KIN E-MAIL