62398 AEQC Supp Online 0107 American Express Form

Supplementary Qantas American Express Card Application YES I would like the Supplementary Qantas American Express Premium Card Card S/C 7X8 173 1 PDT 827/4 Ultimate Card S/C 7X8 184 1 PDT 847/4 S/C 7X8 195 1 PDT 197/4 Name of Basic Cardmember Mr/Mrs/Ms First Name Date of Birth DD/MM/YY Surname Membership Account Number - Name as it would appear on the Supplementary Card max 20 characters Driver s Licence No* Middle Initial Phone No* Relationship to Cardmember By signing below I acknowledge that I have read and agreed to the declaration with respect to Supplementary Cardmembership Credit Cardmember Cardmember Signature of Basic Date / Cnty 872 Fee 2 PLEASE FAX THIS TO 02 9817 7563 OR MAIL TO AMERICAN EXPRESS AUSTRALIA LIMITED REPLY PAID 5148 SYDNEY NSW 2001 DECLARATION IMPORTANT THE BASIC CARD APPLICANT MUST READ THE INFORMATION AND SIGN ABOVE Officer American Express 175 Liverpool Street GPO Box 1582 Sydney NSW 2001. In this section personal information means information about me and the worthiness credit history credit standing credit capacity the use of the Card and conduct of my account with you. I agree that subject to the Privacy Act you and your agents may do the following and if this application is successful this agreement continues until such time as any credit provided to me is repaid Transfer personal information confidentially to your related companies and other organisations which issue or service American Express Cards or provide services to you subject to appropriate conditions of confidentiality. This includes transferring personal information to USA or other countries for data processing and servicing. Monitor and record my telephone conversations with you from time to time in order to train your staff and control your service quality. Provide personal information to any organisation whose name logo or trademark appears on this application or on the Card issued to me for marketing planning product development and research purposes and seek from and exchange with such I also agree that where I have provided you with information about another individual in my supplying their information to you and the purposes why you have collected the information their ability to access that information in accordance with the Privacy Act and advise you if they think the information is inaccurate incomplete or out-of-date and the contact details of your Privacy Officer. Registered Trademark of American Express Company AE5797 AEQC SUPPONLINE 01/07 By signing on the previous page I request you to issue me with the Card specified in the application and I declare that I understand that this is a Card offered issued and administered by American Express Australia Limited you to check that information* I acknowledge that you rely on this information to consider this application I am financially solvent and able to pay all my debts as they fall due You may produce this application or a copy or other reproduction of it as evidence of my application for the Card and my agreement to this Declaration* Invitation I invite you your agents Qantas Airways Limited and your preferred alliance for marketing purposes. This includes contacting me by telephone mail or email to discuss and agree any purchase of goods or services from an any third party providing products jointly marketed with American Express. I remove my name from your marketing lists. Authority to American Express under the Privacy Act To assess this application and if it is approved to establish and manage the Collect personal information about me in this application form and from other sources and Obtain my agreement in relation to the handling of my personal information* If I do not provide the information requested or give my agreement overleaf I understand The American Express Privacy Policy Statement sets out policies on management of inaccurate incomplete or out of date. To arrange access to personal information request a copy of the American Express Privacy Policy Statement or enquire generally about privacy matters write to The Privacy.