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American Express Corporate Card (Billed in Indian Rupees) Individual Cardmember Application
Limited Liability
Please mail completed application to P.O. Box No. 347, Connaught Place, New Delhi 110 001

Work Related Information

Company Name Work Address

Address City Pin

Personal Information
Name as desired on the card (Maximum 20 Characters including word space)

City Tel Extn.

Pin Fax

(Please underline your family name with pen)

Official E-mail address Your Designation

(please specify)

Title Gender

Mr.

Mrs. Male

Ms.

Other Female

Years with Company Corporate ID

Employee No.

Name of Applicant
First Middle Last

If less than one year with the current company, please also provide details of your previous employer: Company Name Your Designation

Declaration by the Individual: I hereby apply to American Express Bank Ltd., (AEBL for an American Express Corporate ) Card and agree to comply with the terms of the agreement which shall be sent alongwith my Corporate Card. I certify that the information given above in support of my application is true and correct. I acknowledge that AEBL, will verify the information with my employer and other sources. I also authorise AEBL. to confirm and exchange credit information about the Company/applicants Account for marketing purposes with its affiliates. I acknowledge and agree that both AEBL, and the Company shall have access to all records arising out of my Corporate Card account. Each Corporate Cardmember shall be liable for all charges. The Company shall be jointly and severally liable for charges, as provided in such conditons of the Corporate Card Account Membership. I declare and undertake that the American Express Corporate Card issued to me if used oversease shall be utilised strictly in accordance with the relevant exchange control regulations, issued and as amended by the Reserve Bank of India (RBI) from time to time. In the event that I exceed my entitlements as per the exchange control guidelines of the RBI, I undertake to bring the same immediately to the notice of AEBL in writting. Further I also agree and understand that if I am required to get my passport endorsed for any such charges incurred by me as stipulated by RBI, the onus of getting the passport endorsed shall lie entirely on me. And in the event of any failure to comply with the prevailing exchange control guidelines issued by RBI by any of the person named by the Company, I will be liable for any action under the Foreign Exchange Regulation Act, 1973 as amended, and be debarred from the Corporate Card facility either at AEBL instance or by the RBI. s I understand that my Corporate Card will be delivered to me within 15 working days of my application being received by American Express, provided all eligibility criteria is met.

Applicants Signature

Nationality Driving Licence No. PAN/GIR No. Passport No. Residential Address

Date of Birth
DD MM YY

City

Tel.

DD

MM

YY

Financial Information
Gross annual taxable Income (Rupees): (Please attach latest copy of TDS 16/last income tax return acknowledged by ITO or latest salary certificate from employer with break up of income) Details of your personal bank account: Name of Bank Address

Name
Declaration by the Company: On behalf of the Company named in this application (the Company), I hereby request issuance of a Corporate Card to the individual named above and certify that the named individual is an employee of the Company. I confirm that the information given in this application form is true and correct and that the Company hereby agree to be bound by the American Express Corporate Cardmember Agreement which will be sent along with the Corporate Card.

Date of Expiry

Signature of authorised signatory and company seal

DD

MM

YY

City Tel. Residential Details Rented

Pin City Mobile Tel. Owned Other (in years) Nature of Account: Savings Current Others
Please specify

Pin Account No.

Name of authorised corporate signatory

Designation

Tel.

Company Provided Tenure at current address

For Office use only

Corporate ID HIR CAP APV DEC CX Cost Centre Source Code

Additional Information
Address to which we should mail your Billing Statements: Residence Work

Are you a current/past American Express Cardmember? Yes No

If Yes, please give Card number(s) 3 3 7 7

If you wish your Corporate Card to be sent to a designated Central recipient in your company, please provide us the relevant details: Central Recipients Name

American Express Bank Ltd., A, A1, A2, Enkay Centre, Udyog Vihar, Phase-V, Gurgaon (Haryana) - 122 016