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Annex - N
CIB ONLINE INQUIRY FORM – 1
Individual’s (Borrower/Co-borrower/Guarantor/Owner) Information
Name of Bank/FI: Prime Bank Limited
FI Code: Branch Code: FI Subject Code:
*Type of Financing:
*Total Requested Amount/Credit Limit:
Installment contract data:
* Number of Installment:
* Installment Amount:
Periodicity of payment:
Role in the Institution:
Chairman
Managing Director
Sponsor Director
Elected Director
Nominated Director (by Govt.)
Nominated Director (by Pvt. Institution)
Shareholder
Partner
Owner of Proprietorship
✓Others
(If the individual is an owner/director/partner of any company then select a role)
Individual Subject Data:
Title:
Manager
*Name:
MUHAMMAD RAFIQUL ISLAM
(Name has to be filled up according to NID/ other ID document)
Father’s Title:
*Father’s Name:
MUHAMMAD FERDOUS MIAH
Mother’s Title:
*Mother’s Name:
MST. ASEA BEGUM
Spouse’s Title:
Spouse’s Name:
NASRIN JAHAN ASHA
NID Number:
-
-
-
-
-
-
-
9
1
2
7
2
6
3
6
3
1
ETIN:
1
7
7
1
3
5
2
0
6
5
4
1
*Date of Birth (DDMMYY):
2
0
1
2
1
9
7
8
*Gender:
✓Male
*District of Birth:
Dhaka
*Country of Birth:
Bangladesh
*Permanent Address:
*District:
Tangail
Village: Patuli
P.O: Barati, P.S: Mirzapur
Postal code:
1944
*Country:
Bangladesh
*Present Address:
*District:
Tangail
Village: Patuli
P.O: Barati, P.S: Mirzapur
Postal code:
1944
*Country:
Bangladesh
Other ID:
*ID Type:
Passport
ID number:
A06169241
ID issue date:
ID issue country:
Bangladesh
*Sector Type:
Private
*Sector code:
Telephone number:
01713-453391
√
Date: 16.04.2024 Signature of the Customer
Seal and signature of the Seal and signature of the
Manager authorized officer.