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CLIENT INFORMATION FORM – INDIVIDUAL

Required as per Capital Markets & Securities Authority Act 1994, Rules Parts IV Section 11(1)(i)&(B)

SECTION 1: APPLICATION DETAILS

Title

Prof

Hon

Rev

Mrs

Miss

Full Name *

Postal Address *

Date of Birth *

Physical Address *

Occupation

Nationality *

NIDA Number / Passport Number *

Telephone Number *

Email Address *

Politically Exposed Person

Not Politically Exposed Person

SECTION 2: BANK ACCOUNT DETAILS

Banker *

Branch *

Account Number *

SECTION 3: NEXT OF KIN DETAILS

Full Name *

Relationship *

Postal Address

Telephone Number *

Email Address

SECTION 4: CLIENT DECLARATION

I hereby declare that the information provided above is true and correct to the best of my knowledge.

Signature *

Date *

SECTION 5: FOR OFFICIAL USE ONLY

Verification Details

Received CDS Receipt / Share Certificate Number

Identification Verified

Received By

Signature

Date

Verification Officer

Verified By

Signature

Date

SUPPORTING DOCUMENTS

National ID *

Passport Copy

Utility Bill

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Bank of Tanzania TMX Online Trading System Regulatory Tume ya Maendeleo ya Ushirika Bodi ya Usimamizi wa Stakabadhi za Ghala

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