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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 PLC.
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:
Mr.
*Name:
Masataka Irie
(Name has to be filled up according to NID/ other ID document)
Father’s Title:
*Father’s Name:
Takeshi Irie
Mother’s Title:
*Mother’s Name:
Ikuko Irie
Spouse’s Title:
Spouse’s Name:
NID Number:
ETIN:
*Date of Birth (DDMMYY):
1
3
1
1
1
9
7
1
*Gender:
Male
*District of Birth:
Tokyo
*Country of Birth:
Japan
*Permanent Address:
*District:
Tokyo
*Street name & number:
372-4, Higashisabi, Gose city, Nara
Postal code:
639-2344
*Country:
Japan
*Present Address:
*District:
Dhaka
*Street name & number:
3-B, # 450/4, Road # 8, Baridhara D.O.H.S
Postal code:
1206
*Country:
Bangladesh
Other ID:
*ID Type:
Passport
ID number:
TM0000077
ID issue date:
26 March 2025
ID issue country:
Japan
*Sector Type:
Private
*Sector code:
Telephone number:
+81 90 1596 8736
√
(Masataka Irie)
Date: 23.10.2025 Signature of the Customer
Seal and signature of the Seal and signature of the
Manager authorized officer
'*' indicates mandatory field