American Express Business Card Application Form

Other Credit or Charge Cards If any American Express Business Card Application Card Bank Name Card Account No* Credit Limit Type of Card Member Since Visa To apply please attach copies of documents listed 1. ID Card for Basic and Supplementary Card Applicants or Passport for foreigner Basic Supplementary Master Card Others 2. Business Registration Certificate including the names of Directors paid up capital and description of business Company Information 3. Bank Statement for the last 6 months that Basic Card Applicant is an authorized signatory Registered Company Name Remark Please certify true copies on every document submitted* Copies of submitted documents to support your application will not be returned* Company Name to appear on Card Application Fee for American Express Business Card Please choose a preferable annual fee type Joining Fee Baht 1 000 per 1 American Express Business Card Account Post Code Business Phone Fax Trading Name if different from company name Type of Business One-flat Fee Baht 3 000 per 1 American Express Business Card Applicant Bundled Fee Baht 8 000 for 1 Basic Card Applicant and up to 4 Supplementary Card Applicants Sole Proprietorship Partnership Corporate Other please specify Nature of Business Annual Pre-Tax Income Baht Business Turnover in the last 2 years Year Baht Net Profit in the last 2 years Billing Address in Thai if applicable Individual Information Basic Applicant Years of Trading Business Paid up Capital Baht Home Office The Basic Cardmember must be the Owner or Authorized Company Signatory of the Company. Name in Thai if applicable Mr. Miss / Bank Reference Bank /19 Account Type ID No*/Passport No* Language Preference If your Company accepts the American Express Card please indicate your Service Establishment No* 9 8 Name in English Date of Birth D/M/Y Card Delivery Address Thai Branch Current Savings Bank English Home Address in English Home Phone Fixed Account Number Mobile Phone Position in Company Years There For American Express Use Only Gross Annual Income Baht If you wish to receive product and service offers from us via e-mail please provide your e-mail address below. E-mail Signature of Basic Card Applicant as in passport Date Source Code Sales ID SBS 29/06/07 Details of Interest Rate Penalty Charges Fees and Other Service Charges 1. Interest Rate Penalty Charges Fees and Other Service Charges N/A Credit Usage Fee Late Payment Fee 20 per annum of Outstanding Balance Fees or Other Service Charges 18 per annum of Extended Payment Plan Start Date of Late Payment Fee Calculation Statement Date 2. Minimum Repayment 3. Cash Withdrawal Fee 3 of Amount Withdrawn 4. Grace Payment Period N/A No Interest on Charge Card 5. Card Fees by Type Baht per annum Adddress Relationship to Basic Cardmember Business Card 1 Basic Card Joining Fee Signature of Supplementary Applicant 2 as in passport 388 S*P. Building Phaholyothin Road Phayathai Bangkok 10400 - Annual Fee Frequent Traveler Option Joining and Annual Fee added 467. 29 6. Payment Fee Direct Debit Free of charge Payment through ATM Overcounter at Bank Payment by Cheque or Money Order 7. Card Replacement Fee 8. Statement Copy Fee 23. 37 Baht / Page 9. Record of Charge Copy Fee Domestic Charge 46. 73 Baht / Transaction Overseas Charge 186. 92 Baht / Transaction 10. ATM PIN Replacement Fee 11. Disputed Charge Fee 12. Returned Cheque Fee 200 Baht / Each returned cheque 13. Credit / Collection Administration Fee Collection Agency/Contractor/Legal Account At Cost Remarks - N/A is Not Applicable. All Fees are excluding VAT Credit or Collection Administration Fee will be shown in the dunning letter. The Frequent Traveler Option at time of Card application* I and Supplementary Cardmembers if any warrant that the information in the application form is true and correct. By signing this application I/we are asking you to open an American Express Business Card Account in my name and to issue me/us an American Express Business Card and Supplementary American Express Business Card s to the person s named on this form* The American shall be liable for all charges on the Card issued at my/our request. I/We agree that a Supplementary Cardmember shall be jointly and severally liable with the American Express Business Cardmember for all charges on such Supplementary Cardmember s each American Express Business Card unless I/we cut the Card in half and return both halves to you. If either you or I cancel my account all American Express Business Card issued on my account will be cancelled automatically. I/We authorize you to verify the information in this application and to receive and exchange information about me/us including requesting information from credit information companies according to the Credit Information Business Act 2002 B. E*2545 or other reference agencies. I/We understand that information provided by you to the credit information companies will be available to other organizations for the purpose of considering whether to grant continue or revise the terms of credit facilities to me/us or any person for whom I/we am/are a surety credit decisioning. I/We authorize you and your affiliates to contact these sources for information at any time to use any information about me/us including information from this application and from information received from credit information companies or other reference agencies for credit decisioning marketing and administrative purposes and to share such information with each other. Information supplied in this application and information about my/our account may be disclosed confidentially to i other companies in the American Express group or its licensees worldwide including any party whose name or logo appears on the Card issued to me/us ii reputable third parties employed by any of the American Express group to provide it with administrative services in connection with the operation of customer accounts and marketing of account services and iii your suppliers and to organizations who accept the Card in payment of goods and/or services purchased by me/us in order to administer and service my/our account process and collect charges on it and manage the benefits or insurance programs in which I/we are enrolled* In so far as applicable and permitted by law I/we shall not withdraw any authorization given above regardless of whether my/our card application is approved or not. Declaration by Company Signatory IES The Company hereby requests issuance of an American herein and certify that the named individual is an employee of the Company. The information given in this application form is to the best of the Company s knowledge true and correct. The Company hereby agrees to be bound by this application and the conditions of use which will be issued with the Card. The Company accepts full liability for all charges incurred on any Card issued on the Card Account bearing the Company name. Name Position Membership Rewards Enrolment Consent Letter to Disclose Credit Information When you are an American Express Business Cardmember you will be enrolled automatically in the Membership Rewards Program* If you wish to enroll in the Membership Rewards Program Frequent Traveler Option please check the box. I Mr. /Mrs. /Miss ID Card/Passport Number I wish to enroll in the Frequent Traveler Option a special category of Membership Rewards. When you enroll in the Frequent Traveler Option a joining fee of Baht 467. 29 and an annual fee of Baht 467. 29 will be automatically charged to your American Express Account. already linked to your Basic Card Account will be enrolled automatically into Membership Rewards and/or the Frequent Traveler Option Program Terms and Conditions. Supplementary Cardmembers cannot hold separate program membership* By signing below I understand that my enrollment is subject to the Membership Rewards and/or Frequent Traveler Option Program Terms and Conditions which will be provided later. This letter of consent has been made voluntarily as an evidence that I consent to the National Credit Bureau Co. Ltd. to disclose or to provide my credit information to its members or its users for the purposes of credit analysis and issuance of credit card including credit review loan extension and credit card renewal or risk mitigation and management pursuant to the Bank of Thailand requirement for every credit accounts that I have with such members or users without having to request additional consent from myself* I also agree that the photocopy fax scanned image or whatever form of record of this original consent letter can be used as evidence of my/our consent.