SUPPLEMENTARY PREMIER MASTERCARD CREDIT CARD APPLICATION

Primary HSBC Premier MasterCard Credit Cardholder Information

Customer Name (same as on current account)

Primary Credit Card No.

ID/ Passport Number Mobile phone No.

Supplementary HSBC Premier MasterCard Credit Card Applicant

I, the Primary Cardholder, hereby request and authorize the Bank to issue a combined Supplementary Credit Card (subject to the
HSBC Premier Master Account Terms and Conditions) to the person identified below, who is over 16 years of age. I understand
that the transactions made on this Supplementary Card will be billed on my statement, and the credit card and PIN for the
Supplementary Card will be mailed to my registered Current Residential Address.

Title  Mr  Mrs  Ms

First Name

Middle Name(s)

Last Name

Preferred Name on Card

(must be in accordance to ID/

Passport, maximum 19 characters including spaces)

Former/Other Name (if any)

ID/ Passport Number Place of issue

Date of issue Date of expiration

Former ID/Passport No. (if any)

Visa Entry Number (if any) Visa valid from (dd/mm/yyyy) to

Date of Birth (dd/mm/yyyy) / /

Place of Birth

Nationality (country/region/territory)
Other nationality 1 (country/region/territory) (if any)

Issued by HSBC Bank (Vietnam) Ltd.

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 Registered Address Street
(in country/territory of Ward, District
nationality 1) City, Country/Territory

Other nationality 2 (country/region/territory) (if any)

Registered Address Street
(in country/territory of Ward, District
nationality2) City, Country/Territory

Residence Status  Resident  Non-resident

US green Card  Yes  No
Resident Alien who has been in the US on at least 31 days during the current calendar year, and 183 days during the 3 year pe riod that
includes the current year and the 2 preceding years.  Yes  No

Relationship with the Primary  Spouse  Child

Cardholder  Premier Joint Account Holder

Current Ressidential Adress (1) Street

Ward, District
City, Country/Territory
Live at Current Ressidential Adress
since (dd/mm/yyyy)

Permanent Adress (2) Street

Ward, District
City, Country/Territory

1. Current Residential Address refers to the address where the customer currently resides.
2. Permanent Address refers to the address where the customer intends to stay permanently.

Previous Ressidential Adress Street

(if stay in current Residential Ward, District
Address less than 3 years) City, Country/Territory
Live at Previous Ressidential Adress
since (dd/mm/yyyy)

(*) If residence duration at previous address and current address combined is less than 3 years, please provide:
Other Previous Ressidential Adress 1 Street
(if stay in current Residential Ward, District
Address less than 3 years) City, Country/Territory

Live at Previous Ressidential Adress 1

since (dd/mm/yyyy)

Issued by HSBC Bank (Vietnam) Ltd.

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 Other Previous Ressidential Adress 2 Street
(if stay in current Residential Ward, District
Address less than 3 years) City, Country/Territory

Live at Previous Ressidential Adress 2

since (dd/mm/yyyy)

I, the Supplementary Card Applicant, would like to link this Supplementary Credit Card with my own below HSBC account(s) for
use at HSBC ATMs around the world.

1. - -
2. - -

Phone Number Office

(please provide at least two) Residence
Mobile

Declaration

I/We confirm that the information given above is correct and complete and authorize the Bank to confirm this from any source the
Bank may choose. I/We acknowledge that the use of the card(s) is subject to Credit Card Cardholder Agreement, Premier Master
Account Terms and Conditions. Credit Card Cardholder Agreement together with this application constitutes a contract for use of
credit card(s) and a copy of which will be sent to me/us on approval of this application. I/We understand that the Bank reser ves the
right to amend the Cardholder Agreement, Premier Master Account Terms and Conditions for Account Holders from time to time,
which will be binding upon me/us, and may notify me/us of any such alterations in any manner it thinks fit. The signature(s) below
shall also be my/our specimen signatures for all transactions relating to my/our card(s).

I/We note that it is a requirement by HSBC that information relating to this application, whether successful or otherwise, must be
updated to the Bank. I/We confirm and agree that the Bank is at liberty to disclose my/our information, including those of the
Supplementary Cardholders, obtained during the process of this application from any source whatsoever, to any of the other HS BC
Group members and/or any person or organization as the Bank may consider necessary for whatever purposes (except for selling my
information for commercial purpose), including relevant authorities in Vietnam or abroad and any service provider, any third party,
any business which the Bank engages during its course of business. Further, the recipient of such information fr om the Bank is
allowed to store and use such information for such purposes as they deem necessary. I/We confirm that any credit card issued to
me/us, including Supplementary Cards issued under my/our account, shall not be used by me/us for or in connection with any
unlawful activity or purpose (including without limitation online gambling), whether in whole or in part.

 I am currently not involved in any Legal arrangement(s) (*) as an entrusted or authorized party.
(*) Legal arrangements are agreements made in writing between domestic and foreign organizations and individuals on entrustment,
authorization for the management and use of money, assets.

Signature and Name of Primary Credit Card Cardholder Signature and Name of Supplementary Credit Card
Applicant

Date Date

Issued by HSBC Bank (Vietnam) Ltd.

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 Document Checklist

 HSBC Supplementary Premier MasterCard Credit Card Application form

 A copy of original ID card for local Vietnamese or Passport with valid term for foreigners of Supplementary Card Applicant

 Other documents

 Address proof for Supplementary Card Applicant

For Bank Use Only

 BL Checked  SCC Checked  CRRT Checked  World-check Checked

Issued by HSBC Bank (Vietnam) Ltd.

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