Customer Data

Customer Data Form

Please fill out the form below to submit your customer data.

All fields are required unless otherwise indicated.

Are You a New Customer? *

Yes No

Surname *

First Name *

Middle Name *

Date of Birth *

Customer Occupation*

Phone Number *

Email Address *

Must match valid universal email standard syntax rules.

Address*

Town/City*

Local Government Area*

State of Residence*

Signature*

Click to upload files or drag and drop

Accepted formats: PNG, JPG, PDF (Maximum data capacity: 10MB)

Passport Photograph*

Click to upload files or drag and drop

Accepted formats: PNG, JPG, PDF (Maximum data capacity: 10MB)

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Savannah EDC Headquarters,
Bauchi Street Adjacent Ministry of Works,
Gombe, Gombe State,
Nigeria.