``` INVESTMENT OPPORTUNITY Dangote Refinery IPO Share Subscription / Investor Registration Form 🔒 Secure Investor Information 01 Applicant Information Please provide your details exactly as reflected in your CSCS records. Applicant Type * IndividualJoint ApplicantCorporate Title * Mr.Mrs.MissDr.Prof.Others Surname / Corporate Name * First Name Other Names Local Government Area of Origin 02 Contact & Address Details Provide accurate contact information for communication and verification. Full Postal Address * City / Town * State * Country * Phone Number * Email Address * Tax Identification Number Date of Birth Mother's Maiden Name Next of Kin / Contact Person * Next of Kin / Contact Phone 03 Investor & CSCS Information Please select your investor status. Existing investors should provide their CSCS and Stockbroker details. New investors may proceed without providing these details. Investor Status * Please Select Investor StatusNew InvestorExisting Investor Existing Investor Please provide your existing CSCS and Stockbroker information exactly as registered with your investment account. CHN Number CSCS Number Name of Stockbroker Member Code New Investor You do not need to provide CSCS or Stockbroker details at this stage. You may proceed with your application. Number of Units * Select the number of units. Units are available in multiples of 10. Cost Per Unit Fixed subscription price per unit. Total Amount Total Amount = Number of Units × ₦525. Upload Evidence of Payment * Account name: SCM CAPITAL LTD / DANGOTE REFINERY COLLECTION ACCOUNT Account Number: 0149584749 Bank Name: Sterling Bank Please note that the transaction reference/remark should read the Subscriber's full name. Upload your payment evidence in PDF, DOC, DOCX, JPG or PNG format. 04 Joint Applicant Details Complete this section where the application is being made jointly. Joint Applicant Title Mr.Mrs.MissDr.Prof.Others Joint Applicant Surname Joint Applicant First Name Joint Applicant Other Names Joint Applicant Date of Birth Joint Applicant Phone Joint Applicant Email Joint Applicant Address 05 Bank Account Details Provide the bank account details associated with your investment application. Bank Name * Account Number * Branch BVN * 06 Corporate Applicant Details Complete this section for corporate applications. RC Number Second BVN 07 Declaration & Consent Please review the declarations before submitting your application. I confirm that the information provided in this application is true, accurate and complete to the best of my knowledge. I understand that the information may be subject to verification and applicable regulatory requirements. I consent to the collection, processing and use of my personal information for purposes connected with this application, subject to the applicable privacy and data protection requirements. 🔒 Data Security Notice Please do not submit passwords, PINs, OTPs or other authentication credentials through this form. By submitting this form, you confirm that you have reviewed the information provided and agree to the applicable terms and conditions. Secure Investor Application ``` Δ
