Cardmember Application, Individual Liability: (For Employees of Accenture)

AMERICAN EXPRESS GOLD CORPORATE CARD
Cardmember Application, Individual Liability (For Employees of Accenture)

Please mail completed application to:
American Express Banking Corp., Cyber City, Tower C, DLF Bldg. No. 8, Sector - 25, DLF City Phase-II, Gurgaon - 122002, Haryana
Completion of all fields is mandatory.
Personal Information
Name as desired on the Corporate Card (Maximum 22 characters including word space):
Title:
Mr.
Mrs.
Gender:
Male
Female
Ms.
Other
Name of Applicant:
(Please specify)
Please affix and sign

across your recent
passport size photo
First Name (in full)
(Name provided should match your Proof of Identity)

Middle Name (in full, if applicable)
Surname (in full)
Nationality:
Date of Birth:
DD
MM
YYYY
PAN/GIR No.:
Please provide your Passport or Driving Licence No., along with its date of expiry:
Passport No.:
Date of Expiry:
Driving Licence No.:
Date of Expiry:
DD
MM
YYYY
DD
MM
YYYY
Residential Address:
(Including City)
Pincode:
Telephone No.:
Mobile No.:
With STD Code
Address to which we should mail your correspondence?

Work address
Are You a current/past American Express Cardmember?
Residential address
No
Yes
If yes, please give Card number(s):

3 7
3 7
E-mail:
All communication regarding your Corporate Card (including your statement alert e-mails) will be sent to this ID.
Work Related Information

Corporation Name (Company):
Corporate ID:
Employee ID:
Work Address:
(Including City)
Pincode:
Work Telephone:
With STD Code
Extn.:
Fax:
With STD Code
Your Designation:
Years with Company:
Gross Annual Taxable Income (In Rupees):
Official E-mail:
YY
MM
If you have worked for less than one year with the current Company, please provide details of your previous employer:
Company Name:
Your Designation:
City:
Telephone No.:
Express Cash Facility
Yes, please enrol me for the Express Cash Facility.

1
No, I do not wish to enrol1 for the Express Cash Facility.
This request will be valid and processed only if your Company is enrolled for this facility.
Membership Rewards
Yes, please enrol me in the American Express Membership Rewards Programme. I agree to be bound by all the terms and conditions of
enrolment2. If yes, please tick () the appropriate box.
Please enrol me in the Membership Rewards Frequent Traveler
Option. I agree that a fee of ` 1,500 will be billed to my Corporate
Card Account each year.
2
Please enrol me in the Membership Rewards Non-Frequent

Traveler Option. I agree that a fee of ` 450 will be billed to my
Corporate Card Account each year.
Confirmation of your enrolment will be sent separately and is subject to your Companys declaration to participate in the Membership Rewards Programme.
Membership Rewards terms and conditions apply. For details log on to www.americanexpress.co.in/membershiprewards
Agreement and Signatures

Declaration by the Individual:
I am applying to American Express Banking Corp. (AEBC) for an American Express Gold Corporate Card (Corporate Card) and agree to comply with the terms
of the agreement, which shall be sent along with my Corporate Card. I certify that the information given above in support of my application is true and correct. I
acknowledge and consent to AEBC verifying the information with my employer and any other sources that it may deem fit. I further agree to provide any further
information that AEBC may require to evaluate and approve my application.
I also authorise AEBC to confirm and exchange credit information about the Company/applicants Account from any source including but not limited to Banks
and Credit Bureaus. I authorise AEBC to share and use my personal information (other than my financial information) provided in this application and transaction
details of the Company Account for availing any special benefits or services by the Company/applicant under the Corporate Card and for any marketing purposes.
3
I understand that my personal and sensitive information shall be stored, used and shared by AEBC in accordance with its Privacy Policy .
I acknowledge and agree that both AEBC, and the Company shall have access to all records arising out of usage of my Corporate Card Account. I understand, agree
and undertake that upon issuance of the Corporate Card, I will be personally and solely liable for all charges incurred on it. I understand that my Corporate Card will
be issued at the sole discretion of AEBC and if approved will be delivered to me within 15 working days of my complete application with all supporting documents
being received by AEBC.
I accept that the additional factor of authentication is mandated by RBI vide letter DPSS.PD.CO.No.223/02.14.003/2011-12, dated August 4, 2011 and use of such
cards for travel related Card Not Present (CNP) transactions without such additional factor of authentication carries security risk and such cards are vulnerable
to frauds.
I do hereby solemnly declare that the information provided above is true to the best of my knowledge and belief. The documents provided as proof of identity and
proof of residence address have been self-attested. I have also attached my recent photograph to this application.
3
For details of the American Express Privacy Policy please log on to http://www.americanexpress.com/india/pdfs/privacy_statement.pdf
Applicants Name:
Applicants Signature
DD
MM
YYYY
Declaration by the Company:

On behalf of the company named in this application (the Company), I hereby request issuance of a Gold Corporate Card to the individual named above and certify
that the named individual is an employee of the Company. I confirm that the information given in this application form is true and correct and that the Company
hereby agrees to be bound by the American Express Corporate Cardmember Agreement which will be sent along with the Corporate Card.
Name of Authorised Corporate Signatory:
Signature of Authorised Signatory and Company Seal
Designation:
DD
MM
YYYY
Please ensure that the Authorised Signatory is not the same as the applicant, and is as captured in
AEBC records.
Tel. No.:
E-mail:
Acceptable KYC (Know Your Customer) Documents List

Please attach a self-attested copy (with the date of attestation) of one Photo Identity Proof and one Residence Address Proof from the below
list. The attestation date should be the same as the date of signing this application.
Passport4
Election/Voters ID Card4
Ration Card4 (with applicants photo)
PAN intimation letter
Any Government institution issued document reflecting residential address/
Authority of Government (less than 3 months old)
UIDAI letter (Aadhar)
Income tax/Wealth tax assessment order
Copy of any Utility Bill (Electricity/Landline/Mobile) showing residential address
(less than 3 months old)
Credit Card/Bank Statement of any Bank in India (other than American Express
and Cooperative Banks) which is less than 3 months old
Registered lease deed
Proof of address issued by Bank Managers of Commercial Banks in India
In case your Passport, Voters ID Card or Ration Card has your current address details along with your date of birth then no additional/separate document is
required to be attached & only the self-attested copy of either of these documents will suffice as both Photo Identity Proof and Residence Address Proof.
Office Use Only

Corporate ID:
HIR CAP
APV DEC CX
Cost Centre:
Source Code:
www.americanexpress.co.in/cs
American Express Banking Corp., Incorporated with Limited Liability in the USA. Registered trademark of American Express Company
VER. 9.1, 04/13
UIDAI letter (Aadhar)

Driving Licence (Permanent)
Residence Address Proof (Any one)
CM/IL/GOLD/ACCENTURE
Passport
Election/Voters ID Card4
Ration Card4 (with applicants photo)
PAN Card
PSU/Govt. Dept./Defense ID Cards
4
FORM-7A
Photo Identity Proof (Any one)

Cardmember Application, Individual Liability: (For Employees of Accenture)

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AMERICAN EXPRESS GOLD CORPORATE CARD

Cardmember Application, Individual Liability (For Employees of Accenture)

Please affix and sign

First Name (in full)

(Name provided should match your Proof of Identity)

Surname (in full)

Driving Licence No.:

With STD Code

Address to which we should mail your correspondence?

Are You a current/past American Express Cardmember?

If yes, please give Card number(s):

Work Related Information

With STD Code

With STD Code

Years with Company:

Gross Annual Taxable Income (In Rupees):

Yes, please enrol me for the Express Cash Facility.

No, I do not wish to enrol1 for the Express Cash Facility.

Please enrol me in the Membership Rewards Non-Frequent

Agreement and Signatures

Declaration by the Company:

Name of Authorised Corporate Signatory:

Signature of Authorised Signatory and Company Seal

Acceptable KYC (Know Your Customer) Documents List

Office Use Only

VER. 9.1, 04/13

UIDAI letter (Aadhar)

Residence Address Proof (Any one)

Photo Identity Proof (Any one)

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