HAVILAH CONCEPT

Shema Filling Station, Abuja

Email: havilahconcept@gmail.com

TEL. NO: 08074308912, 09057355221

N10,000
Non refundable

APPLICATION FORM Affix One

Passport
A. PERSONAL DATA Photograph,
Write Your
Name & Sign
1. NAME OF APPLICANT/COMPANY (IN FULL) _____________________
_____________________________________________________________
2. AGE ______3. SEX____________4. MARITAL STATUS ______________
5. STATE OF ORIGIN________________6. TEL NO____________________
7. DATE OF BIRTH_____8. RESIDENTIAL ADDRESS (STREET, TOWN&
STATE) _____________________________________________________
9. PERMANENT HOME ADDRESS_________________________________
_____________________________________________________________
10. E-MAIL ADDRESS & POSTAL ADDRESS_________________________
_____________________________________________________________
11. OCCUPATION________________________________________________
12. OFFICE ADDRESS____________________________________________
13.NAME(S) OF DIRECTORS______________________________________
_____________________________________________________________
14.NAME & ADDRESS OF NEXT OF KIN____________________________
_____________________________________________________________
15.PHONE NUMBER & EMAIL ADDRESS OF NEXT OF KIN____________
_____________________________________________________________

B. HOW DID YOU KNOW ABOUT US

Agent Flier/Banner Social Media word of Mouth
If referred/Referrals name ______________________ Referral’s phone No__________________
++CATEGORY OF BUILDINGS

LA’ GRACE SITE COMFORT SITE EXPLIOT SITE GLORY SITE

4 bedroom duplex 4 bedroom Bungalow
4 Bedroom Duplex 4BEDROOM DUPLEX
3bedroom Duplex 3 bedroom Bungalow
3 Bedroom Duplex 3BEDROOM DUPLEX
4bedroom DUPLEX 4bedroom Bungalow

3 bedroom DUPLEX 3Bedroom Bungalow

C. MODE OF PAYMENT
FULL PAYMENT PART PAYMENT
-Note that payment should be made after the developer’s approval.
-Letter of allocation will issued on presentation of bank teller, showing payment and verification
of same from the bank.
-Default of any installment paid shall be viewed as withdrawal of interest in the service
plot/building initially allocated. Refund of any and all sum already paid by the allottee shall attract
20% admin charges.
D. DECLARATION
I, ________________________________whose name and address appears above declared that
the information/ statement are true and correct to the best of my knowledge.
And I promise to abide by the rules & regulations given by the developer.
Sign___________________________
FOR OFFICE USE ONLY
Installment Date Amount Balance Mode of Bank/Account Remarks
Plan Paid Payment Paid into
1st
2nd
3rd

Application Checked by: ________________________________________

Date: _________________Plot No/Unit(s) Allocation________________
Sign/Office Stamp