Green And Gold Card Application Form

APPLY TODAY

1

ABOUT MY JOB

4 Office Address

YES, I would like to apply for the American Express Card. Annual Fee: RM140

General line

Position

Type of business Gross annual salary

You are

Sources

Mr.

Old NRIC No.

New NRIC No.

Date of Birth

Passport No. (for non-Malaysians only)

Salaried

Mrs.

Ms.

Nationality

Others

Mobile phone Own property

E-mail Family/Relative

Rented

Permanent home address Postcode To home

To office

MY RELATIONSHIP WITH AMERICAN EXPRESS

3

Are you an American Express Cardmember? Current

In the past

Current card no. (if applicable) 3

7

Never

PLEASE SIGN

9

• • • •

MY FINANCIAL DETAILS

Card Issuer

Member Since

Account No.

SUPPLEMENTARY CARD

Old NRIC No. Credit Limit

Date of Birth

D

M

M

Y

Y

• • • •

Name and address of the nearest relative not living with you. Postcode

Nationality

Others

Passport No. (for non-Malaysians only)

Postcode

Mobile phone

E-mail

Photocopy of the Supplementary Card applicant’s identity card (both sides) Applicant must be 18 years old & above Gold Supplementary Card (annual fee RM125) American Express Supplementary Card (annual fee RM95)

Specimen Signature of Supplementary Applicant

(Please tick one)

YES! Please enrol me in Membership Rewards and bill the amount to my Card Account RM25 annual fees for Non-Frequent Traveler Option

RM50 annual fees for Frequent Traveler Option (inclusive of Non-Frequent Traveler Option) Are you a member of any frequent flyer program? If yes, please indicate program/membership no.:

Yes

No

Signature

11

Date

Postcode

American Express Card Account No. Expiry date

M

M

Y

For office use only

TERMS & CONDITIONS

I/We declare that the above information given by me/us is true and complete. I/We hereby authorize you to verify information on me/us and any supplementary applicant(s) from whatever source you consider appropriate from any financial institution and the Director General of Inland Revenue Department on any information which Malayan Banking Berhad may require. I/We also confirm that none of my/our spouse(s), parents and/or children are employees of Malayan Banking Berhad or Malayan Banking Group. I/We confirm that I/we shall read the Terms and Conditions of the Maybankard American Express Charge Card Agreement and agree to be bound by them and all future amendments thereto before accepting and receiving the card(s). I/We further agree that the Principal Cardmember shall be responsible for all liabilities and obligations of the Principal Cardmember as well as those of the Supplementary Cardmember(s). The Supplementary Cardmember however, shall only be responsible for his/her own liabilities and obligations. The Bank shall reserve the absolute right to approve or reject my/our application as The Bank deems fit without assigning any reason. I/We understand the card(s) remain the property of Malayan Banking Berhad and shall be subject to cancellation without notice and would be returned upon request. I/We hereby agree to you disclosing information to Bank Negara Malaysia regarding my/our credit facilities and my/our account with you, as may be required, whether pursuant to law or otherwise. Malayan Banking Berhad shall not be liable whether directly or indirectly to me/us or any other persons for such disclosure. (For External Account Holders Only) I/We confirm that my /our borrowings from all sources within Malaysia do not exceed in aggregate of RM200,000.

7

3

6

2

Y

New NRIC No. Old NRIC No./Passport No.

Relationship

MEMBERSHIP REWARDS/MILES

7

Ms.

Relationship to Principal Cardmember

REFERENCE

Tel No.

Mrs.

Home address (even if same as Principal Cardmember)

Home phone

6

Cardmember’s Name (as per in NRIC)

Mr.

New NRIC No. D

FOR OFFICE USE ONLY

Address

Name to appear on the Card

Account type

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B) Last 3 months’ company/personal bank statements Form 9, Form 24, Form 49/ Business Registration Certificate/Trading License

For office use only

Full name as in NRIC or Passport (underline surname)

Bank/Branch Account No.

Date

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B/Latest EA Form) Last 2 months’ payslips Last 3 months’ savings account activity/current account statements For Expatriates - letter from your employer confirming duration of employment contract in Malaysia and applicant must be a Maybank account holder

Self Employed

Specimen Signature of Principal Applicant

10

Postcode Home phone

Y

Signature

Self employed - BRC No. if you are self-employed

Present home address (please do not indicate P.O. Box address)

Please send monthly statement

Y

It is important to complete the following to ensure your application is processed as quickly as possible.

Name to appear on the Card

Years there

M

Previous position

5

Full name as in NRIC or Passport (underline surname)

Other income

M

Name of previous employer (if less than 1 year in present employment) Years there

ABOUT MYSELF

Length of employment

• • • • •

No, prefer other modes of payments (i.e. cash, cheque)

No, already enrolled with other cards

Postcode

Direct line

Dept

In order to apply you must: Be over 21 years of age and have a minimum annual income of RM24,000 to qualify for the American Express Card or RM48,000 to qualify for the Gold Card.

2

Yes, tell me more

DOCUMENTS REQUIRED

Individual Applicant (Salaried Employee)

Would you be interested to pay your bills using Express AutoPay?

Company’s Name

YES, I would like to apply for the American Express Gold Card. Annual Fee: RM238

12

EXPRESS AUTOPAY

8

Date of birth

D

D

M

M

Y

Y

Office phone

Home phone

Mobile phone

Occupation

APPLY TODAY

1

ABOUT MY JOB

4 Office Address

YES, I would like to apply for the American Express Card. Annual Fee: RM140

General line

Position

Type of business Gross annual salary

You are

Sources

Mr.

Old NRIC No.

New NRIC No.

Date of Birth

Passport No. (for non-Malaysians only)

Salaried

Mrs.

Ms.

Nationality

Others

Mobile phone Own property

E-mail Family/Relative

Rented

Permanent home address Postcode To home

To office

MY RELATIONSHIP WITH AMERICAN EXPRESS

3

Are you an American Express Cardmember? Current

In the past

Current card no. (if applicable) 3

7

Never

PLEASE SIGN

9

• • • •

MY FINANCIAL DETAILS

Card Issuer

Member Since

Account No.

SUPPLEMENTARY CARD

Old NRIC No. Credit Limit

Date of Birth

D

M

M

Y

Y

• • • •

Name and address of the nearest relative not living with you. Postcode

Nationality

Others

Passport No. (for non-Malaysians only)

Postcode

Mobile phone

E-mail

Photocopy of the Supplementary Card applicant’s identity card (both sides) Applicant must be 18 years old & above Gold Supplementary Card (annual fee RM125) American Express Supplementary Card (annual fee RM95)

Specimen Signature of Supplementary Applicant

(Please tick one)

YES! Please enrol me in Membership Rewards and bill the amount to my Card Account RM25 annual fees for Non-Frequent Traveler Option

RM50 annual fees for Frequent Traveler Option (inclusive of Non-Frequent Traveler Option) Are you a member of any frequent flyer program? If yes, please indicate program/membership no.:

Yes

No

Signature

11

Date

Postcode

American Express Card Account No. Expiry date

M

M

Y

For office use only

TERMS & CONDITIONS

I/We declare that the above information given by me/us is true and complete. I/We hereby authorize you to verify information on me/us and any supplementary applicant(s) from whatever source you consider appropriate from any financial institution and the Director General of Inland Revenue Department on any information which Malayan Banking Berhad may require. I/We also confirm that none of my/our spouse(s), parents and/or children are employees of Malayan Banking Berhad or Malayan Banking Group. I/We confirm that I/we shall read the Terms and Conditions of the Maybankard American Express Charge Card Agreement and agree to be bound by them and all future amendments thereto before accepting and receiving the card(s). I/We further agree that the Principal Cardmember shall be responsible for all liabilities and obligations of the Principal Cardmember as well as those of the Supplementary Cardmember(s). The Supplementary Cardmember however, shall only be responsible for his/her own liabilities and obligations. The Bank shall reserve the absolute right to approve or reject my/our application as The Bank deems fit without assigning any reason. I/We understand the card(s) remain the property of Malayan Banking Berhad and shall be subject to cancellation without notice and would be returned upon request. I/We hereby agree to you disclosing information to Bank Negara Malaysia regarding my/our credit facilities and my/our account with you, as may be required, whether pursuant to law or otherwise. Malayan Banking Berhad shall not be liable whether directly or indirectly to me/us or any other persons for such disclosure. (For External Account Holders Only) I/We confirm that my /our borrowings from all sources within Malaysia do not exceed in aggregate of RM200,000.

7

3

6

2

Y

New NRIC No. Old NRIC No./Passport No.

Relationship

MEMBERSHIP REWARDS/MILES

7

Ms.

Relationship to Principal Cardmember

REFERENCE

Tel No.

Mrs.

Home address (even if same as Principal Cardmember)

Home phone

6

Cardmember’s Name (as per in NRIC)

Mr.

New NRIC No. D

FOR OFFICE USE ONLY

Address

Name to appear on the Card

Account type

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B) Last 3 months’ company/personal bank statements Form 9, Form 24, Form 49/ Business Registration Certificate/Trading License

For office use only

Full name as in NRIC or Passport (underline surname)

Bank/Branch Account No.

Date

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B/Latest EA Form) Last 2 months’ payslips Last 3 months’ savings account activity/current account statements For Expatriates - letter from your employer confirming duration of employment contract in Malaysia and applicant must be a Maybank account holder

Self Employed

Specimen Signature of Principal Applicant

10

Postcode Home phone

Y

Signature

Self employed - BRC No. if you are self-employed

Present home address (please do not indicate P.O. Box address)

Please send monthly statement

Y

It is important to complete the following to ensure your application is processed as quickly as possible.

Name to appear on the Card

Years there

M

Previous position

5

Full name as in NRIC or Passport (underline surname)

Other income

M

Name of previous employer (if less than 1 year in present employment) Years there

ABOUT MYSELF

Length of employment

• • • • •

No, prefer other modes of payments (i.e. cash, cheque)

No, already enrolled with other cards

Postcode

Direct line

Dept

In order to apply you must: Be over 21 years of age and have a minimum annual income of RM24,000 to qualify for the American Express Card or RM48,000 to qualify for the Gold Card.

2

Yes, tell me more

DOCUMENTS REQUIRED

Individual Applicant (Salaried Employee)

Would you be interested to pay your bills using Express AutoPay?

Company’s Name

YES, I would like to apply for the American Express Gold Card. Annual Fee: RM238

12

EXPRESS AUTOPAY

8

Date of birth

D

D

M

M

Y

Y

Office phone

Home phone

Mobile phone

Occupation

APPLY TODAY

1

ABOUT MY JOB

4 Office Address

YES, I would like to apply for the American Express Card. Annual Fee: RM140

General line

Position

Type of business Gross annual salary

You are

Sources

Mr.

Old NRIC No.

New NRIC No.

Date of Birth

Passport No. (for non-Malaysians only)

Salaried

Mrs.

Ms.

Nationality

Others

Mobile phone Own property

E-mail Family/Relative

Rented

Permanent home address Postcode To home

To office

MY RELATIONSHIP WITH AMERICAN EXPRESS

3

Are you an American Express Cardmember? Current

In the past

Current card no. (if applicable) 3

7

Never

PLEASE SIGN

9

• • • •

MY FINANCIAL DETAILS

Card Issuer

Member Since

Account No.

SUPPLEMENTARY CARD

Old NRIC No. Credit Limit

Date of Birth

D

M

M

Y

Y

• • • •

Name and address of the nearest relative not living with you. Postcode

Nationality

Others

Passport No. (for non-Malaysians only)

Postcode

Mobile phone

E-mail

Photocopy of the Supplementary Card applicant’s identity card (both sides) Applicant must be 18 years old & above Gold Supplementary Card (annual fee RM125) American Express Supplementary Card (annual fee RM95)

Specimen Signature of Supplementary Applicant

(Please tick one)

YES! Please enrol me in Membership Rewards and bill the amount to my Card Account RM25 annual fees for Non-Frequent Traveler Option

RM50 annual fees for Frequent Traveler Option (inclusive of Non-Frequent Traveler Option) Are you a member of any frequent flyer program? If yes, please indicate program/membership no.:

Yes

No

Signature

11

Date

Postcode

American Express Card Account No. Expiry date

M

M

Y

For office use only

TERMS & CONDITIONS

I/We declare that the above information given by me/us is true and complete. I/We hereby authorize you to verify information on me/us and any supplementary applicant(s) from whatever source you consider appropriate from any financial institution and the Director General of Inland Revenue Department on any information which Malayan Banking Berhad may require. I/We also confirm that none of my/our spouse(s), parents and/or children are employees of Malayan Banking Berhad or Malayan Banking Group. I/We confirm that I/we shall read the Terms and Conditions of the Maybankard American Express Charge Card Agreement and agree to be bound by them and all future amendments thereto before accepting and receiving the card(s). I/We further agree that the Principal Cardmember shall be responsible for all liabilities and obligations of the Principal Cardmember as well as those of the Supplementary Cardmember(s). The Supplementary Cardmember however, shall only be responsible for his/her own liabilities and obligations. The Bank shall reserve the absolute right to approve or reject my/our application as The Bank deems fit without assigning any reason. I/We understand the card(s) remain the property of Malayan Banking Berhad and shall be subject to cancellation without notice and would be returned upon request. I/We hereby agree to you disclosing information to Bank Negara Malaysia regarding my/our credit facilities and my/our account with you, as may be required, whether pursuant to law or otherwise. Malayan Banking Berhad shall not be liable whether directly or indirectly to me/us or any other persons for such disclosure. (For External Account Holders Only) I/We confirm that my /our borrowings from all sources within Malaysia do not exceed in aggregate of RM200,000.

7

3

6

2

Y

New NRIC No. Old NRIC No./Passport No.

Relationship

MEMBERSHIP REWARDS/MILES

7

Ms.

Relationship to Principal Cardmember

REFERENCE

Tel No.

Mrs.

Home address (even if same as Principal Cardmember)

Home phone

6

Cardmember’s Name (as per in NRIC)

Mr.

New NRIC No. D

FOR OFFICE USE ONLY

Address

Name to appear on the Card

Account type

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B) Last 3 months’ company/personal bank statements Form 9, Form 24, Form 49/ Business Registration Certificate/Trading License

For office use only

Full name as in NRIC or Passport (underline surname)

Bank/Branch Account No.

Date

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B/Latest EA Form) Last 2 months’ payslips Last 3 months’ savings account activity/current account statements For Expatriates - letter from your employer confirming duration of employment contract in Malaysia and applicant must be a Maybank account holder

Self Employed

Specimen Signature of Principal Applicant

10

Postcode Home phone

Y

Signature

Self employed - BRC No. if you are self-employed

Present home address (please do not indicate P.O. Box address)

Please send monthly statement

Y

It is important to complete the following to ensure your application is processed as quickly as possible.

Name to appear on the Card

Years there

M

Previous position

5

Full name as in NRIC or Passport (underline surname)

Other income

M

Name of previous employer (if less than 1 year in present employment) Years there

ABOUT MYSELF

Length of employment

• • • • •

No, prefer other modes of payments (i.e. cash, cheque)

No, already enrolled with other cards

Postcode

Direct line

Dept

In order to apply you must: Be over 21 years of age and have a minimum annual income of RM24,000 to qualify for the American Express Card or RM48,000 to qualify for the Gold Card.

2

Yes, tell me more

DOCUMENTS REQUIRED

Individual Applicant (Salaried Employee)

Would you be interested to pay your bills using Express AutoPay?

Company’s Name

YES, I would like to apply for the American Express Gold Card. Annual Fee: RM238

12

EXPRESS AUTOPAY

8

Date of birth

D

D

M

M

Y

Y

Office phone

Home phone

Mobile phone

Occupation

APPLY TODAY

1

ABOUT MY JOB

4 Office Address

YES, I would like to apply for the American Express Card. Annual Fee: RM140

General line

Position

Type of business Gross annual salary

You are

Sources

Mr.

Old NRIC No.

New NRIC No.

Date of Birth

Passport No. (for non-Malaysians only)

Salaried

Mrs.

Ms.

Nationality

Others

Mobile phone Own property

E-mail Family/Relative

Rented

Permanent home address Postcode To home

To office

MY RELATIONSHIP WITH AMERICAN EXPRESS

3

Are you an American Express Cardmember? Current

In the past

Current card no. (if applicable) 3

7

Never

PLEASE SIGN

9

• • • •

MY FINANCIAL DETAILS

Card Issuer

Member Since

Account No.

SUPPLEMENTARY CARD

Old NRIC No. Credit Limit

Date of Birth

D

M

M

Y

Y

• • • •

Name and address of the nearest relative not living with you. Postcode

Nationality

Others

Passport No. (for non-Malaysians only)

Postcode

Mobile phone

E-mail

Photocopy of the Supplementary Card applicant’s identity card (both sides) Applicant must be 18 years old & above Gold Supplementary Card (annual fee RM125) American Express Supplementary Card (annual fee RM95)

Specimen Signature of Supplementary Applicant

(Please tick one)

YES! Please enrol me in Membership Rewards and bill the amount to my Card Account RM25 annual fees for Non-Frequent Traveler Option

RM50 annual fees for Frequent Traveler Option (inclusive of Non-Frequent Traveler Option) Are you a member of any frequent flyer program? If yes, please indicate program/membership no.:

Yes

No

Signature

11

Date

Postcode

American Express Card Account No. Expiry date

M

M

Y

For office use only

TERMS & CONDITIONS

I/We declare that the above information given by me/us is true and complete. I/We hereby authorize you to verify information on me/us and any supplementary applicant(s) from whatever source you consider appropriate from any financial institution and the Director General of Inland Revenue Department on any information which Malayan Banking Berhad may require. I/We also confirm that none of my/our spouse(s), parents and/or children are employees of Malayan Banking Berhad or Malayan Banking Group. I/We confirm that I/we shall read the Terms and Conditions of the Maybankard American Express Charge Card Agreement and agree to be bound by them and all future amendments thereto before accepting and receiving the card(s). I/We further agree that the Principal Cardmember shall be responsible for all liabilities and obligations of the Principal Cardmember as well as those of the Supplementary Cardmember(s). The Supplementary Cardmember however, shall only be responsible for his/her own liabilities and obligations. The Bank shall reserve the absolute right to approve or reject my/our application as The Bank deems fit without assigning any reason. I/We understand the card(s) remain the property of Malayan Banking Berhad and shall be subject to cancellation without notice and would be returned upon request. I/We hereby agree to you disclosing information to Bank Negara Malaysia regarding my/our credit facilities and my/our account with you, as may be required, whether pursuant to law or otherwise. Malayan Banking Berhad shall not be liable whether directly or indirectly to me/us or any other persons for such disclosure. (For External Account Holders Only) I/We confirm that my /our borrowings from all sources within Malaysia do not exceed in aggregate of RM200,000.

7

3

6

2

Y

New NRIC No. Old NRIC No./Passport No.

Relationship

MEMBERSHIP REWARDS/MILES

7

Ms.

Relationship to Principal Cardmember

REFERENCE

Tel No.

Mrs.

Home address (even if same as Principal Cardmember)

Home phone

6

Cardmember’s Name (as per in NRIC)

Mr.

New NRIC No. D

FOR OFFICE USE ONLY

Address

Name to appear on the Card

Account type

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B) Last 3 months’ company/personal bank statements Form 9, Form 24, Form 49/ Business Registration Certificate/Trading License

For office use only

Full name as in NRIC or Passport (underline surname)

Bank/Branch Account No.

Date

Photocopy of your NRIC (both sides) or passport Income Tax Returns (Form B/Latest EA Form) Last 2 months’ payslips Last 3 months’ savings account activity/current account statements For Expatriates - letter from your employer confirming duration of employment contract in Malaysia and applicant must be a Maybank account holder

Self Employed

Specimen Signature of Principal Applicant

10

Postcode Home phone

Y

Signature

Self employed - BRC No. if you are self-employed

Present home address (please do not indicate P.O. Box address)

Please send monthly statement

Y

It is important to complete the following to ensure your application is processed as quickly as possible.

Name to appear on the Card

Years there

M

Previous position

5

Full name as in NRIC or Passport (underline surname)

Other income

M

Name of previous employer (if less than 1 year in present employment) Years there

ABOUT MYSELF

Length of employment

• • • • •

No, prefer other modes of payments (i.e. cash, cheque)

No, already enrolled with other cards

Postcode

Direct line

Dept

In order to apply you must: Be over 21 years of age and have a minimum annual income of RM24,000 to qualify for the American Express Card or RM48,000 to qualify for the Gold Card.

2

Yes, tell me more

DOCUMENTS REQUIRED

Individual Applicant (Salaried Employee)

Would you be interested to pay your bills using Express AutoPay?

Company’s Name

YES, I would like to apply for the American Express Gold Card. Annual Fee: RM238

12

EXPRESS AUTOPAY

8

Date of birth

D

D

M

M

Y

Y

Office phone

Home phone

Mobile phone

Occupation