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supplementary application form supplementary ... - American Express

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AMERICAN EXPRESS INTERNATIONAL CURRENCY CARDS<br />

List of professionals who can certify your Documentation:<br />

Accountant with a recognised professional qualification<br />

(eg chartered account)<br />

Bank Employee<br />

Registered Lawyer/Barrister/Solicitor<br />

Senior Civil Servant (Individual who has a permanent job<br />

with the Government)<br />

Commissioner of Oaths/Justice of the Peace<br />

Doctor<br />

Engineer with a recognised professional qualification<br />

Member of Parliament<br />

Police Officer<br />

Optician<br />

Post Office official<br />

Chartered Surveyor<br />

Dentist<br />

Example of a Certified Passport, Identity Card or Driving Licence:<br />

IDENTITY CARD<br />

FULL NAME: John Smith<br />

DATE OF BIRTH: 1 Jan 89<br />

NO: 2009-0101-1000-0202<br />

COUNTRY: UK<br />

A valid and true copy of<br />

Passport or Identity Card<br />

or Driving Licence<br />

This must show a<br />

photograph, full name, date<br />

of birth and Passport or<br />

Identity number<br />

I certify that this is a valid and true copy of the original<br />

document and is a true likeness of Mr. A Sample<br />

Application<br />

reference number: 2009-0101-1000-0202<br />

(applicable to online <strong>application</strong>s only)<br />

Original seen<br />

Full name of certifier:<br />

Business<br />

Address:<br />

Telephone number<br />

of certifier<br />

(including dial code):<br />

Signature:<br />

Profession:<br />

Date:<br />

✓<br />

CF Frost<br />

Sample Street<br />

Sample Town<br />

UK<br />

We accept a personal number (mobile or landline) or a<br />

business telephone number (general or direct)<br />

C Frost<br />

Lawyer<br />

01/01/2011<br />

Example of a Certified Proof of Address:<br />

Bank or<br />

Utility<br />

letterhead<br />

A bank statement or utility bill<br />

(on bank or utility letterhead)<br />

dated within the last 3 months<br />

which must have been sent<br />

through the postal service.<br />

I certify that this is a valid and true copy of the original document<br />

Application<br />

reference number: 2009-0101-1000-0202<br />

(applicable to online <strong>application</strong>s only)<br />

Original seen<br />

Full name of certifier:<br />

Business<br />

Address:<br />

Telephone number<br />

of certifier<br />

(including dial code):<br />

Signature:<br />

Profession:<br />

Date:<br />

✓<br />

CF Frost<br />

Sample Street<br />

Sample Town<br />

UK<br />

We accept a personal number (mobile or landline) or a<br />

business telephone number (general or direct)<br />

C Frost<br />

Lawyer<br />

01/01/2011<br />

Please note, we require the certifier to provide their telephone number.<br />

We accept a personal number (mobile or landline) or a business telephone number (general or direct).<br />

<strong>American</strong> <strong>Express</strong> Services Europe Limited<br />

Registered Office: Belgrave House, 76 Buckingham Palace Road, London, SW1W 9AX, United Kingdom<br />

Registered in England and Wales with Company Number 1833139.<br />

<strong>American</strong> <strong>Express</strong> Services Europe Limited is authorised by the Financial Services Authority under the Payment Services<br />

Regulations 2009 415532 for the provision of payment services.

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