Quotation Number fea noo AMERICAN EXPRESS CREDIT CARD APPLICATION FORM 7 ty bone ss compen 8.008 + branch Di srenen ost [2 other Customer Type 1 new eating eat ave Lleatsenstve customer feng sankcard [EJ] amex [] vie [1] amexcorpornte [ote [I] w/a campaign Name + DSt/Employee Code Reference code ate CO ‘yan: to any ocak) } ou [one psu] corn Lote RC ‘Om Om Ome. D1 otter cender J male] remte + Your ull Name ty sas cee (rer) Nickname sional 10 No. ‘xe of sith + Pace of ith Nationality Name on Passport passport sue tssue Oste iy Date Passport No other Documentation smontaisites — [] sree] mares E] overces ——trspouseemotovd? [[] ves [I] no + No.of dependents + Educational Quatfetion Di rostcrasiate FE] crduste E] use D1 otter Contact No. +88 kmail ‘Fathers Name “+ Mother's Name + Spouse's Nome ContaetNo. 188 Profession Senger + Your name a8 you would like Itto appear onthe card Uisve ane space belmoen nares do note eer eran) + carowneshin [] owes [] arents [] omceprovies ] Number of ars |, How doyouwantareceie [EJ FomcBteranch rom tare ese wre te name ofthe rch record? 1 rreth courier “inte eee crsmomter sees receva the cet adn the gen ess the Carnet sume leno iy Bonk i ce ele ora an deur any eof {orm ofoubsenotony fhe eat ead iecneedbyomane pte CrSnener ith Caroneroe aoa soe ronal ot orth mee wag cur oN Ea + Your Residential Status 7 ownes [2] Famiy ownes [F] company srovses [[] rented [1] otner “Residential Address rented, reat per monihin Nearest Landmark + Distiet ty Post cade “+Area/ Police Station “+ Res dence Phone No No.of month at erren adress : ssa HINO 5847_CTB_5377_21_Amex_Card Appli_Design_Form_A4a a a ‘Your Permanent Address (eeinpanpont ‘Area Police Station Neatest andra You are Di satariee LL] setterployes Li busnesenan/tusiats: Cand owner ‘Employment status [I] Permanent [1] contactuat [] partTine ‘Date of ining «oe se are soi os hoe seme tse ont Feepulg corer pe D1 Proprietorhia [7] partnership [1] tmited company + Total work experience in months foes, cash % credit * «Work experience in curent organization in month(s) No.of Employees persons oftce Premisesstatus [J owned [1] rented [1] teased [J other Busnes eabaner ie Ne teh wth met nition Business Figures Details: Year. Year, ‘Year. Catton Anna Profit Anna Turnover RSM a) TE otteeastess — [F]resdentatadires. I] permanent adress Coe you are salaried Bsc (monty) Te Aowances (monthly Tk ‘otal (month) Te + tt youare seemployed {Gress income (monty Tk. Expenses month) Tk Net Income Tk. Adtional monty income Mayet restr documents) Source of other income Income of spouse Te others income oN. Old TW. Pane astReferonce + Reference Name + Occupation ‘Residentiat status [1] owned [Z] Femi owned [Z] company provided [[] tented [Z] other natoratty + Relation wth apa (mice Res Prone 88 MobieNo, +86 mall + Residential dees ‘ees / oie Staton + Company Name Company Adsress 7 HINA vo 7a a a 2nd Reference "+ Reference Name + Oceupaton ‘resident status [] owned [I] Family owned [] comsany provided [7] rented [] other retort + Relation with apleant ‘fn Res Prone 88 + MobieNe. 688 Ena + Residential Ades sea / ote Staton + Company Name + company Adeess [1 E-statements(€-Staterents wil be sent to the emai adress mentioned in the ‘About Yourset section.) LL Forhardcopy statement select anyone) —[] office adress [[] Residence adress Bank Name NC Warne ctype AIC. Aesince 1 2 MATIN St Bankname IC Name ‘Account No. |AlCType —_Disb.Amount Instalment Amount Outstanding Amount 1 2 DETAILS OF OTHER CREDIT CARDS ey Clent10 corte crest iot Cardtype Membersir Bonkname fs.05 gs laos corso Type [Mentor soc 2 ae ee Le) SL Security Type Beneficiary Rate AvCrinrumentNo. Bank Name Issue Date Face Value Present Value 1 EO a Monthy payment] Ys wou to have my Cy Bank's agent automata dite each month or payment of my Ce Cre soo: [i mammamourtave [5] 1oovetouettsina Mle en you acount lb deed forthe (ty Sank Account No. for OT ‘coun. No2 for USO Branch ame EIN a RS Ow Om Doms Loner ender EF] male) remate Name of supplementary Cre aplcat: SS Mame Supplementary Card applicant 2 you woud lke ito appear on the card National 10 No, Nationality Rettonsipwihshe Primary] ssoue [] ren: [] sing E] cott otter PassprtNo mA moss "a a a UE aC oateot 10 Pace of ith ‘caupaton Sowe/name Mathers name dares {ee PolnSaon Date /ty Peet Code ‘Would you lke to set up s of local Credit limit anc Email foams ete Dive the Sollocalc 4 Email Splereary cae? Ow % of USD Creat iit MobieNo, +88 EU Om Om Ome LD otter ender = [J mele =] Female Name of supplementary asta dapget supplementary San spent youl ke to appen aonaity aor Ono Relationship withthe Primary — [] spouse [] rorent (J sioing [J cus other Passport card appcant Date of ih Pace ath ‘ecupston fathers rome osname rs Reertnco Sasres ‘Pole Saton ste /cny ot Code Would you et setup a ves flea Cred tad a you he tet Oe m ‘ofl Cedintand Ena Splememary ca? Ow % of USO rect iit MobleNo. +88 PHOTO Pema Cad Appear Supplementary Card opleantNo.1. Supplementary Crd Appear No.2 Please attach cet olor Peaesttch recent color Please attach recent olor pation se photograh ihis possport ste photograph nh pation se photograph his to write yourname onthe Bock Soe wie your ame one bask {ox wrt yourname on he ack ofthe protganh of te photeerop the protogrash. BE Sen within ares, tse black nkony Primary Card Applicant Supplementary Card Applicant No.1. Supplementary Card Applicant No.2 Enea ee | te Supplementary Cardappicent, gree tobe jt and separately able toat transactions procesred bythe ue ofthe Cardappieforanseuedby CBLtothe rary Cardapaicantand/ortomysl,andtobe bound bya the terms ane condivons ofthe Bank’ sCredit Cars A@reement ‘Senate of Supplementary Card Applicant No.1 Signature of Supplementary Card Applicant No.2 ate noes tNa a a PIM Leroy apply for Ararian Exess ret Cada edo tat the rfonmaton reve inthis apleation treat covet ane |shalladise yous ay changes terete ney authanze Te Cty Bank Lite vey any irermatin trom whatever sarees may cans’ apres Laceat ta The Cty Bank Lind even osehie Sr sal ot be eure fore setrabage an gre thal Te sage ofthe mar Care sneorSupekementary Car) sy. ssud any scent salle dees Ss So Sepranceot the ierme and Congo oe socmert weds uhehay be riences Morin ote) ae sie’ oneal earespngenceconmsted 9 (o cabtted ierendebou)secompanjn te or Sanaa toed Bsa cae cout opera ont peri: Dvir raed tne sy ah aiclcaerpnshca raced ‘conte an acc thal hears ane Conetons efeeahereabores sete charge fom sm tote a Banks escatan ae lune seep met updated wt and Secu lonepersn()nared wie under e e ‘fstjou may pone ntornatentahm/her baste seo. heat the Sipplmenay Care kpplesnt i semcen hae ye ‘halle mace nae my sperionanacarca heey. are to ndeiy te ty Bait aganst ss drage reap unger nah iy of eostnewre bythe Sanson ace of ny teach by reo" te Supplementary Carcnambr) aie sloresnis Concorso ny ater ferms ane Canaan tote ve Bark ie caer ios, ADF ot crust taupe ay her otcameaur settee sooo by veazon oo gal ably or neanaety ate Seplrmetny Ca member lea sdetare tat oe ‘Stpatraiary Care fees sabe sled ny Street sal be my prime’ espns tone eharges meufea onthe Sppietay Car. The conten oe inembersnipel be Supstemaraty Carrere) sal be eepenent one contncaton ny memce sa tama are ht iy Sek Insurance Coverages ee oe beng he Peary Csdrambet- wth THE CITY BANK AMERICAN EXORESS® CREDITCARD, haveuncerstond the Tes Canetars Exelon ng Benefits is vale Protection Scher erg aged betneen 8 sd 7, ape res tte ning to Te Cy Bare Lied eho {tercalodirt iy til nerare program suterahenly upon spening ry Sve Cad scaur andl ancestor sath aerane hot sapheale "othe eanceqeee 9 Slane or oan accent reared pra tomy enter the surance Scere hereby auton the surance Company to very erator a reson wth he haere Scheme rom nhaever sources ray conse spree Ley gree thal tatenens whether rough estatenert seve rave ners ransisen seit he San oy THE ITY BANK AMERICAN EXPRESS® CREDITCARD bolle stented sod celeay me etre and snc dele tat onl a ce ay abet pasta Gon on fs areing tate cre an ul acept ne akan Fesponsiy of states vanseted by Se Bank: The Sa ows ot nara agis ay exer tor ating te pitay ane sec of ma deagintera vars Ith oe pepe Banged aes ea pean abo tra cote ips ena eg 0 te ‘iseantation of hy fly fo cards Dison The Gy Bark Lntea Alan Cerer (th lou) 25/8 Dbz 7A, Daa 1000 The Bark shal a elable respenste ft cts erro eeoy ona” tercepinef he voraton segs an th Barkreseres te gt ope vey eh maton Hay te oie aa oo re amas aay that am pang fer aCe rand Care rertaraas "ete te Appleton ry sete bet your Apa”) agcapng ths delat ashozes the Bank Leshueryeib wm ogenareaPvine teen teeccethew finden te mertansseweh nebo Papaya en We ara cele hat Ve hllseuncer 2 alga erst he Care Dez /Oustndng eye nmeditl nerae th Snkay tke aporop ale lplacon gst Iman Baayen rigs en acetone spre nese ro leapath manne byes: wthhe Bark "ray understetthe ann eh pty the Banat sean onthe erent my ardor dzcontuston the ane CES ene promise to say on demande The Cy dak United or order the um of BT ‘ha ony. Forvalue received wth irtrest tthe rate oF Percent per annum wth moni rts or such rat say be Foedby The Cty Bonk Lmtd rom me to tne DER ae ‘bo youwart AMERICAN BXPRESS*CARO Cheque Book? [TJ] ves [] no DSI am aware that Cy Sel surance Coverages rable forme being th rary Carmember wth he Cy dan Xeric Expres Ce Car. Rave anetoad he Terns (onatons, fxusions and Bors of is vlad insurance Sener Berg gee betweon 18 and 75, grea, ness state wrongs The City Bank Les otherwise, get rrtedni Ci Sei isrance rogram autotily ypon apni of Py ret Cad acount an undestan ha his nstance snl aplcaslet the cansequencs ot $eknee or af an aceident eure prior to my envlimetin the insrane sehr anim Cars ages Seca nord fr 2) arth | hort authore the Isurance company to very the infomasan in eston with thi nance Scheme fam hater surest may oneder appropiate CEASE I/We hereby assign he benef of Cy Shiel Isuranc to Name of Beneiory (sand percentage Shae of Soneft « ‘Name of enefiary Benefit Relation CARDMEMBER’S DECLARATION ON THE RIGHT TO SET OFF ‘Ths detratn orm wil be consered a the integral art of the main Cael Aplin Form (a) In adationto ay general righ to set other rigs contre the ao the ar, Te Catemenber agrees that the Bankr in aso dsteson aay te rd witout noe combine and console lor ary accounts} held ether ndvuaiy ony, of te carrera with the Bank of whatevedeserpson ana wherever Toeated and wheter naa rn any ate eureny se off rUanse an sum standing to the eed of any such aecoues idudg ot acount with ypplementry Caramemberin a owars achat fall ums dua tthe dank unser ary snus) of he Carrserer mith te nk of whatever eatpon or wherever oe 3d \whathern Takao any thecurrency a ay go sonotwhstanding tha the balances such aecoun(] andthe ardmerser hereby autores the Bro oe any Sich ombinnton onsoation, eto or ast withthe ncesarycoovetion atte Gank’sprevalngexhange ats which habe detrmaned by the banka sable ‘rete, (61 For the purpose of enabing the Bank to preserve intact the sty of ary pary inc the Cardmarer orca 2 Wie or Surman as ben sued or prove the ankrupty or insolvency ofthe Cardmenoer or for such other easne athe ar deem fhe Bark ay sy tne on place ndheep such mee the dancnay ink rset any mores recived recovered of ealued Ree unde under any he Seer of Guanes tthe eat othe Caramerbr othe Banks deem two cere ate obgation on te pao te Banko apply the sme or ay pat heeot nor towards the charge ofthe sums ue and owingo te Bank. on am confing that cre Lam ata defate of any bank or ny Banc ntti 2 vests MMIII 7