supplementary application form supplementary ... - American Express
supplementary application form supplementary ... - American Express
supplementary application form supplementary ... - American Express
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
Supplementary Application<br />
Application Two<br />
Supplementary Application<br />
Application Three<br />
Green Business Card<br />
Gold Business Card<br />
Green Business Card<br />
Gold Business Card<br />
Title: Mr Mrs Miss Other<br />
l l l l l<br />
Title: Mr Mrs Miss Other<br />
l l l l l<br />
First Names:<br />
l<br />
l l l l l l l l l l l l l l l<br />
First Names:<br />
l<br />
l l l l l l l l l l l l l l l<br />
l<br />
Family Name: l l l l l l l l l l l l l l l<br />
Relationship to<br />
l<br />
Main Cardmember: l l l l l l l l l l l l l l l<br />
Date of Birth:<br />
D l D l M l M l Y l Y<br />
l<br />
Family Name: l l l l l l l l l l l l l l l<br />
Relationship to<br />
l<br />
Main Cardmember: l l l l l l l l l l l l l l l<br />
Date of Birth:<br />
D l D l M l M l Y l Y<br />
Nationality:<br />
l<br />
l l l l l l l l l l l l l l l<br />
Nationality:<br />
l<br />
l l l l l l l l l l l l l l l<br />
Primary tel number:<br />
(inc. country & area code) l l l l l l l l l l l l l l l l<br />
Email Address: l l l l l l l l l l l l l l l l<br />
Giving us your email address means you agree to us sending you communications (including changes to your terms and<br />
conditions) by email. If you do not want to receive email communication please let us know by calling the number on the reverse<br />
of your Card when you receive it or by updating your email preferences via the privacy statement link on the<br />
<strong>American</strong> <strong>Express</strong> website. Your email address may also be used for servicing or operational purposes.<br />
Please PRINT your name as you wish it to appear on the Supplementary Card in no more<br />
than 20 letters and spaces (initials for first names are acceptable, surname must be in full).<br />
Primary tel number:<br />
(inc. country & area code) l l l l l l l l l l l l l l l l<br />
Email Address: l l l l l l l l l l l l l l l l<br />
Giving us your email address means you agree to us sending you communications (including changes to your terms and<br />
conditions) by email. If you do not want to receive email communication please let us know by calling the number on the reverse<br />
of your Card when you receive it or by updating your email preferences via the privacy statement link on the<br />
<strong>American</strong> <strong>Express</strong> website. Your email address may also be used for servicing or operational purposes.<br />
Please PRINT your name as you wish it to appear on the Supplementary Card in no more<br />
than 20 letters and spaces (initials for first names are acceptable, surname must be in full).<br />
l l l l l l l l l l l l l l l l l l l<br />
Do you have or have you perviously had any other <strong>American</strong> <strong>Express</strong> Card?<br />
l l l l l l l l l l l l l l l l l l l<br />
Do you have or have you perviously had any other <strong>American</strong> <strong>Express</strong> Card?<br />
Please provide a valid and certified true copy of proof of your identity. Select the type of<br />
document and enter the document number:<br />
Please provide a valid and certified true copy of proof of your identity. Select the type of<br />
document and enter the document number:<br />
Passport Drivers licence ID Card<br />
Document<br />
l<br />
Number: l l l l l l l l l l l l l l l<br />
Please make sure you submit all documentation. See the 'Important' box checklist.<br />
If your permanent home address is the same as the Main Cardmember please tick here:<br />
If different, please give your permanent home address including country and postal code.<br />
Passport Drivers licence ID Card<br />
Document<br />
l<br />
Number: l l l l l l l l l l l l l l l<br />
Please make sure you submit all documentation. See the 'Important' box checklist.<br />
If your permanent home address is the same as the Main Cardmember please tick here:<br />
If different, please give your permanent home address including country and postal code.<br />
Address:<br />
Address:<br />
l<br />
l l l l l l l l l l l l l l l<br />
l<br />
l l l l l l l l l l l l l l l<br />
l<br />
l l l l l l l l l l l l l l l<br />
l<br />
l l l l l l l l l l l l l l l<br />
City:<br />
Country &<br />
Postal code:<br />
City:<br />
Country &<br />
Postal code:<br />
l<br />
l l l l l l l l l l l l l l l<br />
l<br />
l l l l l l l l l l l l l l l<br />
l<br />
l l l l l l l l l l l l l l l<br />
l<br />
l l l l l l l l l l l l l l l<br />
Your PIN<br />
Your PIN<br />
A 4-digit Personal Identification Number (PIN) will be required to access cash and may be<br />
required to make purchases. Please select below:<br />
I would like to personally choose a PIN for my Card<br />
You will be contacted by email or telephone to select a PIN and we may hold your Card Application to allow time for this.<br />
I would like you to automatically issue me a PIN for my Card<br />
Please note if you do not select either option above or have not supplied your email or<br />
telephone number on your <strong>application</strong>, you will be issued with a system generated PIN.<br />
I accept joint and several liability with the Main Cardmember for all charges incurred on the<br />
Supplementary Card issued to me. I agree to be bound by the terms of this <strong>application</strong> and<br />
the Cardmember Agreement which will accompany the Card when issued. By signing below,<br />
I confirm that I have read and agree to all the terms and conditions, including the paragraphs<br />
referring to personal in<strong>form</strong>ation contained on this <strong>application</strong> <strong>form</strong>.<br />
A 4-digit Personal Identification Number (PIN) will be required to access cash and may be<br />
required to make purchases. Please select below:<br />
I would like to personally choose a PIN for my Card<br />
You will be contacted by email or telephone to select a PIN and we may hold your Card Application to allow time for this.<br />
I would like you to automatically issue me a PIN for my Card<br />
Please note if you do not select either option above or have not supplied your email or<br />
telephone number on your <strong>application</strong>, you will be issued with a system generated PIN.<br />
I accept joint and several liability with the Main Cardmember for all charges incurred on the<br />
Supplementary Card issued to me. I agree to be bound by the terms of this <strong>application</strong> and<br />
the Cardmember Agreement which will accompany the Card when issued. By signing below,<br />
I confirm that I have read and agree to all the terms and conditions, including the paragraphs<br />
referring to personal in<strong>form</strong>ation contained on this <strong>application</strong> <strong>form</strong>.<br />
Signature of Supplementary Card Applicant<br />
D D M M Y Y<br />
Signature of Supplementary Card Applicant<br />
D D M M Y Y<br />
Date Signed<br />
Date Signed<br />
2