KYC Account Application - Empower Bank staging server

Application for lite account

1. Account Details

Account number (For EmpowerBank official/Agent use only)

Bank card number (For EmpowerBank official/Agent use only)

MyPowerLink Account

PowerKids Account

2. Personal Details

Title *

If Other, please specify

Gender *

Surname *

First name(s) *

Date of Birth (dd/mm/yy) *

National ID *

Physical address *

Mobile Number (263-) *

Email *

3. Next of Kin

Full name *

Relationship *

Contact Number *

4. Personal Pledge

I will select a four-digit PIN (Personal identification number) which I promise not to disclose to any person not even an EmpowerBank staff member (Do not write your PIN on the card or keep it with the card). *

If under 16 years of age to be signed by parent/guardian

Parent name (if under 16)

Parent National ID (if under 16)

Parent Contact number (if under 16)

Customer signature *

Date (dd/mm/yy) *

Acceptance of the Terms and Conditions

You hereby confirm that you have read understood and agree to be bound by the EmpowerBank lite account terms and Conditions *

Name *

Surname *

National ID Number *

Signature *

Date (dd/mm/yy) *

Branch/Agent Official Use Only

ORIGINAL IDENTIFICATION Document CHECKED BY (copy to be attached)

Signature

Date (dd/mm/yy)

Back Office Section

Form and proof of identity Received By

Date (dd/mm/yy)

Form and proof of identity Checked By

ID Checked By

Yes No

Signature