Vision Dreaming

You are required to Fill the form below, post your view, opinion, comment or any related ideas you want us to put in place. Download the Client Registration Form.

CLIENT REGISTRATION FORM

Clients visiting our office for the first time are most welcome. Please complete this form as fully as possible.

Date: ___________/____________/_____________

Last Name:________________________ First Name:_____________________________

Surname: ______________________________

Address:

_______________________________________________________________________________________

City: ___________________ State: ________________ Country: _________________

Phone Numbers: Home: ______________________ Work: _____________________

Mobile: _________________________________________________

Please check the primary contact number above.

Email Address: _______________________________________________________

Employer Name:

___________________________________________________________________

Employer Address:

_______________________________________________________________________

How did you know about our dealings and Office?

 _______________________________________________________________________

Summarized your issues:

 __________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Reason for visit?

_______________________________________________________________________________________

PAYMENT POLICY

Full payment is required at the time of consultation. A 100% payment is required on all cases. All payments must be made either to the Bank or at the office. Please be advised, any payment made can not be refund.

Please indicate your choice of payment method: ________ Cash _________Cheque.

Account Number: 3020800332 (NAIRA ACCOUNT), Account Name: Olukunle Oluwole B. Bank Name: POLARIS BANK LIMITED

OR

Account Number: 0620281995 (DOLLAR ACCOUNT), Account Name: Olukunle Oluwole Benjamin, Bank Name: WEMA BANK PLC

Stipulated fees for consultation: N12, 000 (Five Thousand Naira only). $32 US Dollar

Note: You are to make a compensation fees after your issues might be solved, this fees are to be decided by you, which are voluntary payment.

We hope the above are convenient for you. I hereby agree and accept to pay any costs and charges necessary for my service.

Name: ______________________________________________________________,

Signature_________________________Date:_________________________

FOR OFFICIAL USE ONLY

NAME:

________________________________________________________________________________

Signature_______________________________ Date: __________________

…………………………………………………………………………………………………………………...

RECEIPT OF PAYMENT

NAME:

______________________________________________________________________________

being payment for:

_____________________________________________________________________

the sum of:

____________________________________________________________________________

Signature: _________________________________ Date: _____________________

Please send your completed form with the stipulated registration fees to the office with details of payment or scanned to the email address at [email protected].