Membership form for Dragons' Den Investment Trust (D-DIT)

Dragons' Den Investment Trust (D-DIT)
Members Details Form
Full Names
PrefixFirst NameMiddle NameLast Name
Date of Birth
DayMonthYear
2 digit day, 2 digit month, 4 digit year1
Sex
Marital Status
Employment Status
Member Bank Details
Bank Name: please provide the name of your bank*
Account Name: please provide your name as held by the bank*
Account Number: please provide your NUBAN*
Mobile Number
Country CodePhone Number
Permanent Address
Street Address
Street Address Line 2
CityState / Province / County
Landmark/Post/Zip codeCountry
Email
example@example.com
Next of Kin details
Full Names
PrefixFirst NameLast Name
Relationship
Contact Number
Country CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province /County
Landmark/Postal/Zip CodeCountry
Email
example@example.com
Consent
By accepting to complete this membership form, I give my consent to the processing of my personal data by Dragon’s Den Investment Trust.
My consent is given for taking any action in respect of personal data which may be necessary to achieve the objectives of the club, including, without limitation: collection, systematization, accumulation, storage, clarification (updates, changes), use, distribution (including disclosure), depersonalization, blocking, destruction as well as any other action with personal data in accordance with the effective laws of the Federal Republic of Nigeria.
Consent Accepted
Member Signature
Clear
Please verify that you are human
Should be Empty: