Additional Account Holder Information Form
Having read our terms and conditions and Account Opening Guide, please complete this form in BLOCK CAPITALS ensuring that all account holders sign the
appropriate declaration at the bottom of this form. Please note, if the required identity documentation or tax information is not provided, your
application may be delayed or rejected. If at any stage you require assistance please contact us on +44 (0) 1624 696000. Please note there can only be a
maximum of four account holders per account
Details of the account number(s) to which the following additional holder(s) are to be added:
1. First additional account holder
2. Second additional account holder
Mr Mrs Miss MsOther
Mr Mrs Miss MsOther
First name(s) in full
First name(s) in full
Surname
Surname
(if applicable)
Maiden/former name
Sex
Date of birth
Male
DD
Female
MM
Sex
YYYY
Date of birth
Place of birth
Place of birth
Nationality
Nationality
Are you a US Citizen?
Yes (if applicable)
Maiden/former name
No
Male
DD
Are you a US Citizen?
Female
MM
Yes YYYY
No
Under new international tax and information exchange agreements your
country of tax residence AND National Insurance Number or Tax Identification
Number (TIN) must be provided.
Under new international tax and information exchange agreements your
country of tax residence AND National Insurance Number or Tax Identification
Number (TIN) must be provided.
Country of tax residence
Country of tax residence
National Insurance No /
Tax Identification No (TIN)
National Insurance No /
Tax Identification No (TIN)
Are you tax resident in
any other country?
Yes Are you tax resident in
any other country?
No
Yes No
2nd country of tax residence
(if applicable)
2nd country of tax residence
(if applicable)
2nd country National Ins No/TIN
(if applicable)
2nd country National Ins No/TIN
(if applicable)
Permanent
residential address
Permanent
residential address
(‘Care Of’ addresses and PO
boxes are not permitted)
(‘Care Of’ addresses and PO
boxes are not permitted)
Postcode
Postcode
Correspondence
address
Correspondence
address
(If you would like your mail
delivered to a different address
than your residential address
please detail here)
(If you would like your mail
delivered to a different address
than your residential address
please detail here)
Postcode
Home tel number
Home tel number
Work tel number
Work tel number
Mobile tel number
Mobile tel number
Fax number
Fax number
E-mail address
E-mail address
Occupation
Occupation
(if retired, state retired and
previous occupation)
Postcode
(if retired, state retired and
previous occupation)
Employer’s name
Employer’s name
(previous if retired)
(previous if retired)
Employer’s address
Employer’s address
(previous if retired)
(previous if retired)
Postcode
Annual income range
(approx. Sterling equivalent) Relationship with first
named account holder
£0-25k
£25-50k
£50-100k
Postcode
£100k+
Annual income range
(approx. Sterling equivalent) Relationship with first
named account holder
£0-25k
£25-50k
£50-100k
£100k+
3. Compulsory Account Information
Any named party entrusted with a prominent public position
Please provide details where applicable for any named party who is entrusted with a prominent public position or has been entrusted with a prominent public
position in the past, full details must be provided. Please see the ‘Account opening guide’ or our website for further details.
We reserve the right to request further information and/or evidence to support your answers, before withdrawals are permitted. In addition, we may request
further information/evidence from you during your account relationship with us, should the level of activity on your account change significantly.
4. Automatic Exchange of Information to Improve International Tax Compliance
As a customer of Nationwide International your interest will be paid gross of tax. It is your responsibility to declare any gross interest you have received to your
tax authority. If you are a resident of the Isle of Man, or the European Union, or a citizen of the United States of America, or resident in a country that has
signed an International Tax Information Exchange agreement to which the Isle of Man is party, Nationwide International may disclose your personal and account
details to the Isle of Man Government and these details will be passed on to the tax authorities in the relevant country(ies) as appropriate.
5. Declaration - Additional Account Holders
This must be signed by ALL additional account holders before they can be added to the account.
1. I/We agree to be added to the account(s) as detailed on this form.
2. I/We declare that the money deposited is held by us as joint beneficial owners. In the event of the death of either/any account holder the account shall be
vested in the name(s) of the survivor(s).
3. I/We declare that I/we have read a copy of the terms and conditions and agree to be bound by them.
4. I/We declare that I/we understand that this/these deposit account(s) is/are governed by Isle of Man law exclusively and that the investment, plus any interest,
will only be repaid out of the society office based in Douglas, Isle of Man.
Information you provide on this application form will be held on a computer by Nationwide International and will be used only for purposes registered under the
Isle of Man Data Protection Act 2002 or which you have consented to. As part of our service we may occasionally keep you informed of special offers, products
and services either by letter, telephone or e-mail. If you do not wish to receive this information, please tick this box
. It may take a short time for your
decision to show in our records, in any event, your details will not be passed to any third party.
Signature first additional account holder
Signature second additional account holder
Date
Date
6. Declaration - Existing Account Holders
1. I/We agree to add the above additional account holder(s) to my/our account(s) as detailed on this form and authorise the release of any information regarding
the past operation of the account(s) to the additional joint account holder(s).
2. I/We declare that the money deposited is held by us as joint beneficial owners. In the event of the death of either/any account holder the account shall be
vested in the name(s) of the survivor(s).
3. I/We declare that the operation of the account(s) is/are:
Please tick ONE box only. If you wish to operate your account using the Telebanking or Internet Banking Service, you will need to tick ‘Any one signature’
Any one signature
All signatures together
Information you provide on this application form will be held on a computer by Nationwide International and will be used only for purposes registered under the
Isle of Man Data Protection Act 2002 or which you have consented to. As part of our service we may occasionally keep you informed of special offers, products
and services either by letter, telephone or e-mail. If you do not wish to receive this information, please tick this box
. It may take a short time for your
decision to show in our records, in any event, your details will not be passed to any third party.
Signature first existing account holder
Signature second existing account holder
Date
Date
Signature third existing account holder Date
Nationwide Building Society is authorised in the UK by the Prudential Regulation Authority and is regulated by the Financial Conduct Authority and Prudential Regulation
Authority under registration number 106078. It has its head office at Nationwide House, Pipers Way, Swindon, SN38 1NW. Nationwide Building Society’s branch in the Isle of Man,
trading as Nationwide International, is licensed by the Isle of Man Financial Services Authority. Nationwide Building Society’s principal place of business in the Isle of Man is
5-11 St Georges Street, Douglas, Isle of Man, IM99 1RN. The latest report and accounts are available at nationwide.co.uk
NI27 (December 2015)