Welcome to the World of American Express Form

Page 1 5 13 AM 3/19/08 Suppli-GOLD ram Suppli-GOLD P O S TA G E WILL BE PA I D BY ADDRESSEE S U P P L E M E N TA RY G O L D CREDIT CARD A P P L I C AT I O N F O R M world of American Express Cyber City Tower C DLF Bldg. No*8 Sector - 25 DLF City Ph-ll Gurgaon - 122002 To PERMIT NO. BR-D C - 120/2001 GPO NEW DELHI - 110 001 BUSINESS REPLY ARTICLE Welcome to the NO NECESSARY IF POSTED IN INDIA THE GOLD CREDIT CARD Page 2 AMERICAN EXPRESS YES I would like a Supplementary Gold Credit Card s. Supplementary Gold Credit Cardmembership is available for your dependent family members above 18 years of age. Please fill in capital letters Name of Basic Gold Credit Cardmember First Middle Supplementary Gold Credit Card 1 Name Mr. Ms. Last Others Please specify Name as desired on the Card leave one space blank between names Sex Male Date of Birth Day Female Mth Yr His/Her Relationship to me Membership Fees The Supplementary Gold Credit Card does not carry any joining fee. Each Supplementary Credit Card carries an annual fee of Rs. 1000. Please do not enclose Membership fees with this application* It will be billed to your Credit Card account later. C A R D M E M B E R U N D E RTA K I N G I/We the undersigned warrant that the above information is true and correct and by signing this form I/We above ask that an American Express Credit Card Account s be opened for me/us and for Credit Cards to be issued as requested including renewal and replacement Cards. I/We authorize American Express Banking Corp* AEBC to verify information in this application and to receive and exchange information about me/us including requesting reports from my/our Bank consumer credit or reference schemes. I /We authorize AEBL and its affiliates to contact these sources for information at any time to use information from this application and from consumer credit reports for marketing and administrative purposes and to share such information with each other. I/We agree to be bound by the Terms and Conditions of use which will accompany the Credit Card s if and when the Credit Card is issued to me/us. I/We declare and undertake that the Credit Cards issued to me/us if used overseas shall be utilized 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/We exceed my/our entitlements as per the Exchange Control Guidelines of the RBI we undertake to bring the same immediately to the notice of AEBL in writing. Further I/We also agree and understand that the onus of getting my/our passport endorsed/not endorsed for any charges incurred by me/us shall lie entirely on me/us. And in the event of my failure to comply with the prevailing Exchange Control Guidelines issued by RBI I/We shall be liable for any action under the Foreign Exchange Management Act 1999 as amended and be debarred from the Credit Card facility either at AEBL s instance or by the RBI. I/We understand that the Basic Credit Cardmember will be liable for all charges incurred with the Basic Credit Card and any Supplementary Credit Card. The Supplementary Credit Cardmember accepts joint and several responsibility for all charges incurred on the Supplementary Card issued to him/her.