American_Express_Gold_Card

8/7/2019 American_Express_Gold_Card

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Please Turn Overleaf

Please share with us how you would like your name to appear on the Card

Maximum 24 characters

The Annual Membership Fee for the American Express Gold Card is Rs. 3900/- plus taxes. It covers the Annual Fee for one Basic Card for the Card member, oneAdditional Card, up to two Supplementary Cards and membership into Frequent Traveller Option of the American Express Membership Rewards Programme.

However, membership to the American Express Gold Card is complimentary for the first year which includes the Annual Fee for the Basic Card and up to twoSupplementary Cards.

Application form for the American Express Gold Card

PERSONAL INFORMATION

Title: Mr. Ms. Other (Please specify):

Name:First Middle Last

Gender: Male Female Date of Birth: D D / M M / Y Y Residential Status: Resident Indian Non Resident Indian

Nationality: Driving Licence/Passport No.: PAN No. :

Residential Address:

City: PIN:

Phone No. (Home): With STD Code Mobile No.:

Email: Education: Last University/College :

Marital Status: Married Single Residential Details: Own Home Rented Company Lease Other

Tenure at current address: Year Month

Vehicle Car: Brand/Make/Model: Where would you like to receive your statement? Office Address Home Address

FINANCIAL PARTICULARS

Gross Annual Income: Signature:

Principal Bank Name: Type of Account: Savings Current Others

Account No.: No. of Years Account Held: Year Month

Other Financial details (In Rs.) Mutual Funds Shares Insurance Others:

Yes, I want to apply for an Additional Card to separate different categories of expenditure.

All fields are mandatory

Employment Status: Salaried Self Employed Organisations Name:

Industry/Nature of Business: Current Designation:

Office Address:

City: PIN:

Office Phone No. (Board): With STD Code Extn. No.: Office Phone No. (Direct): With STD Code

Years at Current Business/Organisation (For salaried only):

If you are self employed, please fill in the following details:- Turnover No. of Employees Years in Business Net Profit

OCCUPATION INFORMATION


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Supplementary Credit Card 1* (Supplementary Credit Card member must be over 18 years of age)

Mr. Ms. Other (Please specify):

Name as desired on the Card:

Name:

First Middle Last

Date of Birth: D D / M M / Y Y

Family relationship with Basic Credit Card member:

SUPPLEMENTARY CREDIT CARD

Supplementary Credit Card 2* (Supplementary Credit Card member must be over 18 years of age)

Mr. Ms. Other (Please specify):

Name as desired on the Card:

Name:

First Middle Last

Date of Birth: D D / M M / Y Y

Family relationship with Basic Credit Card member:

Source Code: MR Code: MUD Code: ST Code:

These documents are mandatory and copies submitted need to be self attested by the applicants:a. For Salaried - Latest Form 16/personal Income Tax return acknowledged by I.T.O. OR Latest Salary Certificate/monthly pay slip from employer with the break up or Latest

Salary Certificate/monthly pay slip from employer with the break up and a copy of company ID proof. (the Salary Certificate/monthly pay slip is accepted only ifemployed with a Government, Public Limited or a Multinational company)

b. For Self Employed - Latest personal Income Tax return acknowledged by I.T.O.

c. Identity proof (eg. passport, driving licence etc.) and residential proof (eg. phone bill, electricity bill, passport etc.)

d. Visiting Card

e. Photo ID proof of Supplementary Card member indicating date of birth.

f. Please provide seperate document supports for ID proof and address proof

INCOME DOCUMENTS REQUIRED

TELE-MARKETING COMMUNICATION

Yes, I agree to receive all marketing communication and offers on my American Express Gold Card through telemarketing channels notwithstanding my telephonenumber being registered in any Do not call registry list. I understand I can withdraw my consent at any point of time by registering with the American Express Do Not CallRegistry by calling the Helpline numbers mentioned at the back of the Card.

Signature:

I/we, confirm and warrant that the above information is true and correct and by signing this form, I/we above request that an American Express Gold Card Account(s) be opened for me/us and for American Express Gold Card(Card(s)) to be issued as requested (including renewal and replacement of Card(s)). I/we authorize American Express Banking Corp. (AEBC) to verify information in this appli cation and to receive and exchange information aboutme/us, including requesting reports from my/our Bank, consumer credit, reference schemes or credit bureaus and CIBIL. I/we authorize AEBC and its affiliates to contact these sources for information at any time, to use informationfrom this application and from consumer credit reports, for marketing and administrative purpose and to share such information with each other. If and when the Card(s) is/are issued to me/us, I/we declare and undertake thatthe Card(s) issued to me/us, if used overseas, shall be utilised strictly in accordance with the relevant exchange control regulations issued and as amended by the Reserve Bank of India (RBI), f rom time to time. In the event thatI/we exceed my/our entitlements as per the Exchange Control Guidelines of the RBI, I/we undertake to bri ng the same immediately to the notice of AEBC, in writing. Obtaining any approval from RBI for excess foreign exchangespending shall be my/our responsibility and I/we undertake to ensure strict compliance of the prevailing Exchange Control Regulations. I/we understand that the Basic Card member will be liable for a ll charges incurred on theBasic Card, any Addi tional Card(s) and any/all Supplementary Card(s). The Supplementary Card member accepts joint and several responsibility for all charges incurred on the Supplementary Card issued to him/her. I/we agree tobe bound by the Card member Terms and Conditions of use, which will accompany the Card(s). I/we confirm that American Express has shared the Most Important Terms and Conditions (MITC) for the American ExpressGold Card, with me/us in compliance of the RBI master circular on Credit Card operations of banks and I/we have read, understood and accept the MITC and agree to sign this undertaking. I/we understand that AEBC may declinethis application at its absolute and sole discretion.

CARD MEMBER UNDERTAKING AND SIGNATURE

Basic Applicants Signature: Date:

CREDIT CARDS/ LOANS OWNED

Issuer/Bank: Card No.:

Credit Limit: No. of Years Held:

Issuer/Bank: Card No.:

Credit Limit: No. of Years Held: Existing Relationship with us: American Express Card American Express Service Establishment

Existing Card/Merchant No.:

Loan Account Number (if any) Bank name from where loan is taken

Type of loan: Auto Home Personel Other

*Up to two Supplementary Cards may be issued to your Card Account at no extra cost. The Annual Membership Fee for the third Supplementary Card onwards is Rs. 1500/- plus applicable taxes for each Card. In case you wish to

apply for more than two Supplementary Cards, please call the Gold Card services helpline after you have recieved your Basic Card membership.


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ECS ENROLLMENT FORM

FORM B

I, the undersigned hold a Charge Card.

I understand that Charge Card means any Basic Charge Card issued by American Express that has the trade mark, or logo or service mark, or the name American Express eitherin conjunction with any other name or otherwise on the face of it.

I wish to avail of the Direct Debit facility and hereby express my unconditional consent to debit payment of the amount of the monthly bills of my Card Account (or of anyreplacement/renewal Card that may be issued on the Card Account in lieu thereof) through participation in the Electronic Clearing System (ECS) of the National ClearingCell of the Reserve Bank of India. I also unconditionally and irrevocably authorize American Express Banking Corp. (AEBC) to raise debits for such regular payments againstmy

Bank Account Number , with Bank.

I hereby declare that the particulars given above are true and complete.

If the transactions based on my above instructions are delayed, or are not affected for any reasons whatsoever, I agree not to hold AEBC responsible for any loss/damage/inconvenience that may arise.

I agree and understand that may bank shall be informed of this authorization as per the enclosed letter. Also, I understand that the above instructions cannot be withdrawn/cancelledexcept after due intimation and with the written consent of AEBC for the payment of the Card dues.

Note: Please complete in all respects.Signature of Account Holder : Date:

FORM A

To

American Express Banking Corp.

Cyber City, Tower C, DLF Bldg. No.8

Sector-25, DLF City, Phase-II

Gurgaon-122 002

Dear Sir,

Re: AUTHORISATION TO PAY CHARGE CARD BILLS THROUGH THE ELECTRONIC DEBIT CLEARING SYSTEM*

1. Name:

2. Card Number: 3 7 6 9 1

3. Particulars of Bank Account

a) Name of Account Holder: b) Bank Name: c) Branch Address:

d) 9 digit code number of the bank and branch appearing on the MICR cheque issued by the bank: (Please attach a cancelled blank cheque or its photocopy)

e) Account type: f) Ledger Folio Number:(Savings/Current/CC Account) with code 10/11/13 (If appearing on the cheque book)

g) Account Number: (As appearing on the cheque book)

Yes, I have attached a cancelled blank cheque or its photocopy

*For Bank Account in Delhi, Mumbai, Chennai, Bengaluru and Kolkata only.

Signature of Account Holder : Date:

FORM C

To

The Manager: Bank Name:

Bank Address:

Dear Sir,

I, the undersigned hold an American Express Card and wish to avail of the Electronic Clearing System offered by the Reserve Bank of India towards settlement of my monthlyCard bills.

I have a Bank account having Account Name Account Number with your Bank. I herebyauthorize you to debit month on month, to my above mentioned account, my monthly dues on my Card as raised by American Express Banking Corp. (AEBC).

I further request you to inform AEBC of any changes in the status of my account. Once the American Express Card gets renewed for membership, the ECS facility attachedto the Card will get automatically renewed.

Start Date - The date of signing the form

End Date - Till revoked by me in writing to American Express Banking Corp. and to you.

Signature of Account Holder : Date: Copy of cancelled cheque attached


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STANDING INSTRUCTIONS FOR SERVICE PROVIDERS

PLEASE ATTACH RECENT COPY OF THE SERVICE PROVIDERS BILLS

DETAILS FOR CARD MEMBERS SIGNING UP FOR STANDING INSTRUCTIONS WITH BILLDESK

Name of the Card member: Date of Birth:

Address: City:

PIN: Mobile No*: Email*:

As it appears on the Card

*To ensure timely communication on the status of your application, please fill in your mobile number and email ID. Forms without mobile number will not be registered.

Please continue to pay your bills until you receive confirmation from BillDesk regarding the activation of your Standing Instructions

For any enquiries, please contact BillDesk at 022-40920015 (between 9:30am and 6pm, Monday to Saturday) or e-mail Customer Support Desk at [email protected]

Yes, I would like to earn Membership Rewards Points by giving Standing Instructions for the below mentioned Utility Service Providers to be charged to my

American Express Gold Card.

Airtel

Reliance

Vodafone

Tata IndicomIdea

Loop Mobile

Spice Telecom

Utility Company:

Telephone no:

Cust ID/Account no:

Subscriber name:

City:

Opt-Out

Airtel

Reliance

Vodafone

Tata IndicomIdea

Loop Mobile

Spice Telecom

Utility Company:

Telephone no:

Cust ID/Account no:

Subscriber name:

City:

Opt-Out

MOBILE & LANDLINE

Airtel

Reliance

Vodafone

Tata IndicomIdea

Loop Mobile

Spice Telecom

Utility Company:

Telephone no:

Cust ID/Account no:

Subscriber name:

City:

Opt-Out

Airtel

Reliance

Vodafone

Tata IndicomIdea

Loop Mobile

Spice Telecom

Utility Company:

Telephone no:

Cust ID/Account no:

Subscriber name:

City:

Opt-Out

#Electricity: Standing Instruction available only for Low Tension connections.

##2.5% surcharge applicable on MSEB & MGL

BSES

NDPL

Reliance Energy

MSEB##

MGL##

BESTTATA POWER

Utility Company:

Cust ID/Cons no/CRN:

Cycle no (Rel):

Billing unit (MSEB):Processing cycle (MSEB):

Subscriber name:

City:

Opt-Out

BSES

NDPL

Reliance Energy

MSEB##

MGL##

BESTTATA POWER

Utility Company:

Cust ID/Cons no/CRN:

Cycle no (Rel):

Billing unit (MSEB):Processing cycle (MSEB):

Subscriber name:

City:

Opt-Out

ELECTRICITY

INSURANCE

LIC

Reliance LifeSBI Life

Tata AIG Life

ICICI Prudential

AVIVA

Birla Sun Life

Bharti AXA

Insurance Company:

Policy no:

Premium Amount:

Client ID (For AVIVA/Birla Sun Life):

Policyholder name 1. For Bharti AXA:

2. ICICI Prudential:Opt-Out

LIC

Reliance LifeSBI Life

Tata AIG Life

ICICI Prudential

AVIVA

Birla Sun Life

Bharti AXA

Insurance Company:

Policy no:

Premium Amount:




LIC

Reliance Life

SBI Life

Tata AIG LifeICICI Prudential

AVIVA

Birla Sun Life

Bharti AXA

Insurance Company:

Policy no:

Premium Amount:




LIC

Reliance Life

SBI Life

Tata AIG LifeICICI Prudential

AVIVA

Birla Sun Life

Bharti AXA

Insurance Company:

Policy no:

Premium Amount:





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Facility of Opt-Out Option

This is a Standing Instruction for automatic monthly debit of Utility Bill/s payment with a facility to Opt-Out in case the Card member does notwant any particular bill to be charged on his American Express Card (Card). The Card member will receive an SMS before the bill due date, detailingthe amount of the bill that will be debited to the Card. The Card member would have to revert to the SMS in the specified format and withinthe mentioned time frame to stop processing of that particular payment on the Card, should the Card member desire to Opt-Out. In the absenceof revert from the Card member, the bill will be automatically charged to the Card account.

I authorize American Express to write my Card details in the box above on my behalf, and share the same with BillDesk (Service Provider) for enrollment into the Standing Instructions.I also authorize and express my unconditional consent to the Service Provider for debiting my American Express Card Account (or of any renewal/ replacement Card that may be issued inthe Card account in lieu thereof) on a recurring basis with the full amount of all charges including the monthly bill and any interim charges pertaining to my utility connection (the reference/customer/relationship number as stated above in the form). I have read, agreed and understood the terms as provided alongside and voluntarily and unconditionally undertake that: This Standing Instruction will be effective for the full amount and shall apply only if my American Express Card Account (Card) is valid and in good standing The Service Provider may atits sole discretion accept or decline this Standing Instruction as provided by me My Standing Instruction is in respect of the entire charges on my utility service/connection and the saidinstruction shall be valid and binding for the validity period and subsequent renewal period of the Card unless and until the same has been rescinded by me in writing and the said communicationhas been received by the Service Provider I hereby authorize BillDesk and American Express to exchange/compare information pertaining to my Card. Resultantly, the Service Provider mayreceive from American Express updated information on my Card including but not limited only to changes in Card numbers, expiration dates and status. I understand and am cognizant of thefact that the results of such exchange/comparison may also be used by the Service Provider and/or American Express for the purpose of taking any action, including adverse action againstme The record of charges in respect of the above services received or availed by the Service Provider to the Card will neither bear my signatures nor the imprint of my Card. I thereforeundertake to unconditionally honor and pay without demure and contestation all the said charges including interim charges booked by me under this facility as and when I am billed for thesame by American Express The Service provider will continue to send me bills at regular frequency for the above utility service/facility as per the normal process I will continue to makepayments toward my utility service until I receive a confirmation from BillDesk that my service request has been activated.

(For American Express Use only)

American Express Gold Card No.: Expiry Date: M M / Y Y

Basic Applicants Signature: Date:

Terms & Conditions

Standing Instruction for direct debit to American Express Card Account (Card) will be for the full amount shown on the monthly bill inclusiveof all interim charges levied by the Service Provider/Utility Company for the utility connection of the American Express Card member(Card member) It is clear that American Express is only a facilitator and a mode of payment for the Card member and is not responsible or liablefor any omissions or commissions with regard to the acceptance of the Standing Instruction forms for and on behalf of the Service Provider Signingof the Standing Instruction form by the Card member and payment of the first Service Provider bill will be sufficient proof to establish the authenticityof the Card member instruction to debit his/her Card with the monthly bill and any interim charges for his/her utility connection All such chargesto the Card are subject to authorization by American Express. In case of transactions being declined, the Card member is required or is liable tomake the payment by alternate means, such as cash/cheque, failing which, the Service Provider could restrict the utility connection facilities/services American Express reserves the right to revoke/stop the facility if the credit behaviour on the Card is unsatisfactory or if it believes that continueduse of this facility is not in interest of the Bank It would be the responsibility of the Card member to inform BillDesk, in writing, of any changeor withdrawal of the BillDesk facility thus availed. Failure of the Card member to do the same and subsequent debits, if any, towards the utilitypayments will constitute valid transactions and the Card member will be liable to pay the same Card member is required to fill a revisedStanding Instruction form in case of any change in Card number due to replacement upgrade or downgrade American Express is neither responsiblenor guarantees the quality of services and nor is it liable for any defect or deficiency in the said services so obtained/availed and shall also notby be liable for any loss/damage/claim that may arise out of the use or non use of any such services availed by the Card members. American Expressand BillDesk reserve the right to change/alter/modify/withdraw the offer, utility companies or the Terms and Conditions of this program, at any

time, without prior notice Nothing expressed or implied in the offer shall any way waive or amend any of the Terms and Conditions of the existingCard member agreement Any disputes arising out of disconnection of the Utility/Facility, penalty from the government and late charges oninstallment dues arising due to change/revocation of the facility will be the sole responsibility of the Card member and the Card member will nothold American Express responsible for the same All disputes arising out of this program shall be subject to the exclusive jurisdiction of competentcourts in the State of Delhi.


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RCPGLD/042010

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American_Express_Gold_Card