FIRST GOLD CAPITAL RESOURCES LIMITED APPLICATION FORM APPLICATION DETAILS Application Date Service(s) Required DrugConnect Service DrugFinance Service Credit Guarantee Service Credit Facilitation Service SECTION A: APPLICANT INFORMATION Full Name Date of Birth Gender MaleFemale Marital Status Residential Address State LGA Phone Number Alternative Phone Email Address Nationality Occupation Employer / Business Monthly Income SECTION B: IDENTIFICATION Type of ID Submitted [radio* id-type use_label_element "NIN" "Voter's Card" "Driver's Licence" "International Passport"] ID Number Upload Identification Document SECTION C: NEXT OF KIN Full Name Relationship Phone Number Address SECTION D: SERVICE DETAILS DRUGCONNECT SERVICE The DrugConnect application form is #1500 for each times request is made for direct drugs delivery excluded cost of medications. Nature of Request Drug Availability Search Prescription Assistance Drug Delivery Hospital/Pharmacy Referral Prescription Attached? YesNo Upload Prescription Additional Details DRUGFINANCE SERVICE Application cost for DrugFinance is #5000 for 2 years service but negotiations necessary.This service targeted on people who are on permanent life saving medications. Duration of payment of medications or drugs determine the application additional costs. Purpose of Finance Purchase of Prescription DrugsMedical ConsumablesHospital BillsOther Other Purpose Amount Requested Repayment Period Details of Request CREDIT GUARANTEE SERVICE The Credit guarantee application form is #5000 Purpose of Loan Loan Amount Required Financial Institution Loan Duration CREDIT FACILITATION SERVICE Purpose of Credit Amount Requested Preferred Lender Repayment Duration SECTION E: BANK DETAILS Bank Name Account Name Account Number BVN SECTION F: GUARANTOR INFORMATION Guarantor's Full Name Relationship Phone Number Address Occupation Employer / Business SECTION G: DECLARATION I hereby declare that the information supplied in this application is true, complete and correct to the best of my knowledge. I authorize First Gold Capital Resources Limited to verify the information provided in this application and, where necessary and legally permissible, obtain relevant information from appropriate institutions or third parties for the purpose of assessing and processing my application. I understand that submission of this application does not constitute approval or guarantee of any service, finance, credit facility or credit guarantee. I agree to comply with the applicable terms and conditions governing the service(s) for which I have applied. [acceptance* declaration] I confirm that I have read and agree to the declaration and applicable terms and conditions. [/acceptance] IMPORTANT NOTICE: First Gold Capital Resources Limited reserves the right to accept or reject any application. Registration or application for any of our services does not automatically qualify an applicant for approval. All applications are assessed and approved based on applicable eligibility criteria, merits, requirements, terms and conditions. Submission of an application does not constitute a guarantee of approval.
