Customer Information Form
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1
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3Form Revision Date: 02 Mar 2009
INTERNAL USE ONLY
___________________
Branch:
___________________
CIF #:
CUSTOMER INFORMATION FORM
A. PERSONAL INFORMATION
Title
Date of Birth:
Marital Status:
(Mrs, Mr, Miss, Dr, etc.):
Gender (M/F):
Single
Married
Divorced
Separated
Widowed
Day Month
Year
Last Name:
Alias / Pet Name:
First Name:
Nationality:
Middle Name:
Country of Birth:
Maiden Name:
TRN:
SSN/SIN/TIN:
Mother’s Name:
NIS:
Mother’s Maiden Name:
Father’s Name:
Home Telephone Number
(including country and area code):
Cell Number
Please write the number of dependents in the relevant age group(s):
(including country and area code):
Under 13 yrs
13 - 17 yrs
18 - 29 yrs
Email Address:
30 - 39 yrs
40 - 49 yrs
50 – 60 yrs
Over 60 yrs
Property Ownership (eg. Apartment, Land, House, etc):
Mail Preference:
Own
Rent/Lease
Other, please specify:
Post
Email
B. ADDRESS:
Current Home Address:
Street Number:
Street Name:
Town/District:
Post Office:
Parish:
Country:
Mailing Address (if different from above):
Street Number:
Street Name:
Town/District:
Post Office:
Parish:
Country:
Previous Home Address (if changed within the last five years):
Street Number:
Street Name:
Town/District:
Post Office:
Parish:
Country:
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Parent category: Business