INUKA FUND ORBIT SECURITIES CO.
TLD
FOMU YA MAOMBI YA UWEKEZAJI (INVESTMENT APPLICATION FORM)
CHAGUA MOJA: Binafsi: Akaunti ya Pamoja: Mtoto chini ya Miaka 18:
(Select One) (Individual) (Joint) (Minor Investor)
Kampuni / Taasisi / Kikundi
(Company /Institution / Group)
TAARIFA YA MWOMBAJI WA KWANZA
(1ST APPLICANT'S INFORMATION)
Jina la Kwanza: Jina la Kati: Jina la Ukoo:
(First Name) (Middle Name) (Surname)
Tarehe ya Kuzaliwa: Jinsia Mwanaume Mwanamke
(Date of Birth) (Gender) (Male) (Female)
Aina ya Kitambulisho: Kitambulisho cha uraia Leseni ya udereva Namba ya Mpiga Kura Pasipoti
(Type of Identifacation) (NIDA) (Driving License) (Election Card) (Passport)
Namba ya Kitambulisho: Namba ya utambulisho ya mlipa kodi:
(Identification Number) (Tax Id No (Tin))
Namba ya Simu: Barua Pepe:
(Mobile No) (Email)
TAARIFA YA MWOMBAJI WA PILI
(2ND APPLICANT'S INFORMATION)
Jina la Kwanza: Jina la Kati: Jina la Ukoo:
(First Name) (Middle Name) (Surname)
Tarehe ya Kuzaliwa: Jinsia Mwanaume Mwanamke
(Date of Birth) (Gender) (Male) (Female)
Aina ya Kitambulisho: Kitambulisho cha uraia Leseni ya udereva Namba ya Mpiga Kura Pasipoti
(Type of Identifacation) (NIDA) (Driving License) (Election Card) (Passport)
Namba ya Kitambulisho: Namba ya utambulisho ya mlipa kodi:
(Identification Number) (Tax Id No (Tin))
Namba ya Simu: Barua Pepe:
(Mobile No) (Email)
TAARIFA YA TAASISI, KAMPUNI, KIKUNDI N.K
(INFORMATION OF COMPANY /INSTITUTION / GROUP)
Jina la Kampuni/ Taasisi/ Kikundi: Namba ya usajili:
(Name of the Company /Institution / Group) (Registration No)
Cheti Cha Usajili: Nchi ya Usajili:
(Certificate of Registration) (YES) (NO) (Country of Registration)
Aina ya Biashara Namba ya utambulisho ya mlipa kodi:
(Type of Business)) (Tax Id No (Tin))
Namba ya Simu: Barua Pepe:
(Phone No) (Email)
Namba ya Mawasiliano:
(Contact Person’s No)
MAJINA KAMILI YA MZAZI/MLEZI (KAMA MWOMBAJI WA KWANZA YUKO CHINI YA MIAKA 18)
(FULL NAME OF PARENT/GUARDIAN (IF THE PRIMARY APPLICANT IS UNDER 18 YEARS OLD))
Jina la Kwanza: Jina la Kati: Jina la Ukoo:
(First Name) (Middle Name) (Surname)
Tarehe ya Kuzaliwa: Jinsia Mwanaume Mwanamke
(Date of Birth) (Gender) (Male) (Female)
Aina ya Kitambulisho: Kitambulisho cha uraia Leseni ya udereva Namba ya Mpiga Kura Pasipoti
(Type of Identifacation) (NIDA) (Driving License) (Election Card) (Passport)
Namba ya Kitambulisho: Namba ya utambulisho ya mlipa kodi:
(Identification Number) (Tax Id No (Tin))
Namba ya Simu: Barua Pepe:
(Mobile No) (Email)
ANWANI YA MAKAZI
(RESIDENTIAL ADDRESS ENQUIRY)
Namba ya Nyumba: Wilaya:
(House Number) (District)
Mkoa: Sanduku la Posta:
(Region) (Postal Address)
TAARIFA ZA KIBENKI ZA MWEKEZAJI
(CUSTOMER'S BANK DETAILS)
Jina la Benki: Tawi la Benki:
(Bank Name) (Bank Branch)
Jina la Akaunti: Nambari ya Akaunti:
(Account Name) (Account Number)
CHANZO CHA KIPATO
(SOURCE OF INCOME)
Mshahara Biashara Vyanzo Vinginevyo:
(Salary) (Business) (Other Sources)
Tafadhali fafanua kama umechagua vyanzo vingine:
(Please explain if you have chosen other sources)
TAARIFA ZA MRITHI
(DETAILS OF THE NOMINESS(S))
Sr. Jina Kamili Akaunti Namba Tarehe ya kuzaliwa Asilimia ya umiliki Uhusiano
No. Full Name Account Number Date of Birth % of Ownership Relationship
AKAUNTI YA AMANA
(DEPOSIT ACCOUNT)
Jina la Akaunti:
(Account Name) INUKA MONEY MARKET FUND COLLECTION ACC
Nambari ya Akaunti:
Account Number
01DI012665400
Benki:
(Bank) CRDB BANK PLC
MALIPO
(PAYMENT)
Namba ya akaunti ya Mwekezaji Kiasi kilicholipwa ( kwa Tarakimu TSH):
Investor Account Number Paid Amount (in figures TZS)
Kiasi kilicholipwa ( kwa Maneno TSH):
Paid Amount (in words TZS)
Idadi ya vipande vilivyonunuliwa:
No. of units bought
SAHIHI YA MWOMBAJI NA TAREHE
SIGNATURE OF THE APPLICANT AND DATE
Mwombaji wa Kwanza Mwombaji wa Pili Tarehe:
1st Applicant 2nd Applicant Date
Jina: Jina:
Name Name
Sahihi Sahihi
Signature Signature
KWA MATUMIZI YA OFISI
(For official Use)
Fomu imepitiwa: Fomu imeidhinishwa na
Document reviewed Document Approved by
Jina: Jina:
Name Name ( ORBIT )
Sahihi na Muhuri wa Ofisa wa Wakala Sahihi na Muhuri
Signature & Stamp of Collecting Agent Signature & Stamp( ORBIT )
HATI YA UTAMBULISHO
ACKNOWLDGEMENT SLIP
Namba ya akaunti ya Mwekezaji
Investor Account Number
Jina la muombaji:
First Applicant Name
Kiasi kilicholipwa ( Kwa Tarakimu TSH):
Amount paid (in figures TZS)
Idadi ya vipande vilivyonunuliwa:
No. of units bought
Sahihi na Muhuri wa Ofisa wa Wakala
Signature & Stamp of Collecting Agent
FOR MORE INFORMATION, CONTACT
KWA MAELEZO ZAIDI WASILIAN NA
Orbit Securities Co. Ltd at P.O. Box 70254, Dar es Salaam, 4th floor, Golden Jubilee Tower, Ohio Street.
Call +255 22 2111758, +255 711 803 634, or +255 743 677 873, email inuka@[Link], or visit
[Link]
