Download Supplementary Application Form (PDF) - HSBC

SUPPLEMENTARY PREMIER MASTERCARD CREDIT CARD APPLICATION
Customer Name
Primary HSBC Premier MasterCard Credit Card Holder Information
Credit Card Number
- -
-
ID/Passport Number
Telephone Number
Supplementary HSBC Premier MasterCard Credit Card Applicant
I, the Primary Cardholder, hereby request and authorise the Bank to issue a combined Supplementary Credit Card (subject to the HSBC Premier Master
Account Terms and Conditions) to the person identified below, who is over 16 years of age. I understand that the transactions made on this Supplementary Card
will be billed on my statement, and the credit card and PIN for the Supplementary Card will be mailed to my registered Residential Address.
Title Mr Mrs Ms
First Name
Middle name(s)
Last Name
Preferred Name on the card
(must be in accordance to ID/
Passport maximum 19
characters including spaces)
Former/Other Name
(if any)
ID/Passport Number
Date of Issue
(dd/mm/yyyy)
Place of Issue
Nationality
Residence Status Resident Non-resident
Country of Residence
US Green card Yes No
Resident Alien who has been in the US on at least 31 days during the current calendar year, and 183 days during the 3 year period that includes the current year
and the 2 preceding years.
Yes
No
Date of Birth
(dd/mm/yyyy)
Place of Birth
Relationship with
the Primary Card Holder
Spouse* Child* Premier Joint Account Holder
*Note: Relationship proof must be submitted together with this application.
Residential Address is the
same as that of the Primary
Card Holder
Yes
No (please specify below)**
Residential Address (1)
Street
Ward, District
Issued by HSBC Bank (Vietnam) Ltd. PRE-001/0510-FO-EN/SCC
Page 1 of 2

City, Country
Registered Address (2)
(if different from the
Residential Address)
Street
Ward, District
City, Country
Permanent Address (3)
(if different from the
Residential Address)
Street
Ward, District
City, Country
**Please enclose the address proof for the Residential address of the Supplementary Card Holder. The address proof for the permanent address is also required if it is
different from the residential address.
I, the Supplementary Card Applicant, would like to link this Supplementary Credit Card with my own below HSBC account(s) for use at HSBC ATMs around the
world
- -
- -
Phone Number
(please provide at least two)
Office
Residence
Mobile
Declaration
I/We confirm that the information given above is correct and complete and authorise the Bank to confirm this from any source the Bank may choose. I/We
acknowledge that the use of the card(s) is subject to Credit Card Cardholder Agreement, HSBC’s General Terms and Conditions for Account Holders. Credit
Card Cardholder Agreement together with this application constitutes a contract for use of credit card(s) and a copy of which will be sent to me/us on
approval of this application. I/We understand that the Bank reserves the right to amend the Cardholder Agreement, HSBC’s General Terms and Conditions
for Account Holders from time to time, which will be binding upon me/us, and may notify me/us of any such alterations in any manner it thinks fit. The
signature(s) below shall also be my/our specimen signatures for all transactions relating to my/our card(s).
I/We note that it is a requirement by HSBC that information relating to this application, whether successful or otherwise, must be updated to the Bank. I/We
confirm and agree that the Bank is at liberty to disclose my/our information, including those of the Supplementary Cardholders, obtained during the process of this
application from any source whatsoever, to any of the other HSBC Group members and/or any person or organisation as the Bank may consider necessary for
whatever purposes including relevant authorities in Vietnam or abroad and any service provider, any third party, any business which the Bank engages during its
course of business. Further, the recipient of such information from the Bank is allowed to store and use such information for such purposes as they deem necessary.
I/We confirm that any credit card issued to me/us, including Supplementary Cards issued under my/our account, shall not be used by me/us for or in connection
with any unlawful activity or purpose (including without limitation online gambling), whether in whole or in part.
Signature of Primary Credit Card Cardholder
Signature of Supplementary Credit Card Applicant
Date
Date
Document Checklist
01 copy of ID (for Vietnamese) or Passport (for foreigner) of the Supplementary Card Applicant
HSBC Premier MasterCard Credit Card Application form
Address proof
Relationship proof (if any)
Other document
For Bank use only
BL Checked SCC Checked CRRT Checked World-check done
1. Residential Address refers to the address where the customer currently resides.
2. Registered Address refers to :for Vietnamese: the Household Registered Address ; for Foreigner: the Overseas Registered Address
3. Permanent Address refers to the address where the customer intends to stay permanently.
Issued by HSBC Bank (Vietnam) Ltd. PRE-001/0510-FO-EN/SCC Page 2 of 2