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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:
Chairman
*Name:
Mr. Yo Osumi
(Name has to be filled up according to NID/ other ID document)
Father’s Title:
*Father’s Name:
Hiroshi Osumi
Mother’s Title:
*Mother’s Name:
Chizuko Osumi
Spouse’s Title:
Spouse’s Name:
NID Number:
ETIN:
*Date of Birth (DDMMYY):
1
8
0
2
1
9
6
1
*Gender:
Male
*District of Birth:
Tokyo
*Country of Birth:
Japan
*Permanent Address:
*District:
Tokyo
*Street name & number:
2-10-10 Nishi-Ikebukuro, Toshima
Postal code:
171-0021
*Country:
Japan
*Present Address:
*District:
Tokyo
*Street name & number:
2-10-10 Nishi-Ikebukuro, Toshima
Postal code:
171-0021
*Country:
Japan
Other ID:
*ID Type:
Passport
ID number:
TR8929979
ID issue date:
18 August 2017
ID issue country:
Japan
*Sector Type:
Private
*Sector code:
Telephone number:
+81-80-5188-8948
🗸
(Yo Osumi)
Date: 23.10.2025 Signature of the Customer
Seal and signature of the Seal and signature of the
Manager authorized officer
'*' indicates mandatory field