Fill and Sign the Dv 001 Standard Domestic Relationship Incident Report 0604 Michigan Form

Supplementary Qantas American Express Card Application YES I would like the Supplementary Qantas American Express Premium Card YES I would like the Supplementary Qantas American Express Card S/C: 7X8Ø173ØØ1 PDT: 827/4 YES I would like the Supplementary Qantas American Express Ultimate Card S/C: 7X8Ø184ØØ1 PDT: 847/4 S/C: 7X8Ø195ØØ1 PDT: 197/4 Supplementary Applicant 2 Name of Basic Cardmember (Mr/Mrs/Ms) First Name Date of Birth (DD/MM/YY) Surname Membership Account Number 3 7 6 0 - Name as it would appear on the Supplementary Card (max 20 characters) Supplementary Applicant 1 (Mr/Mrs/Ms) First Name Date of Birth (DD/MM/YY) Driver’s Licence No. Middle Initial Phone No. Surname Relationship to Cardmember Name as it would appear on the Supplementary Card (max 20 characters) Date of Birth (DD/MM/YY) By signing below, I acknowledge that I have read and agreed to the declaration with respect to Supplementary Cardmembership Driver’s Licence No. Phone No. ✘ Relationship to Cardmember Credit Cardmember Cardmember Signature of Basic Date / / Cnty: 872 Fee: 2 PLEASE FAX THIS TO (02) 9817 7563 OR MAIL TO AMERICAN EXPRESS AUSTRALIA LIMITED, REPLY PAID 5148, SYDNEY NSW 2001 DECLARATION IMPORTANT: THE BASIC CARD APPLICANT MUST READ THE INFORMATION AND SIGN ABOVE Officer, American Express, 175 Liverpool Street, GPO Box 1582, Sydney NSW 2001. In this section, 'personal information' means information about me and the Supplementary Card applicant, including about my financial circumstances, my credit worthiness, credit history, credit standing, credit capacity, the use of the Card and conduct of my account with you. I agree that, subject to the Privacy Act, you and your agents may do the following (and if this application is successful, this agreement continues until such time as any credit provided to me is repaid): • Transfer personal information confidentially to your related companies and other organisations which issue or service American Express Cards or provide services to you, subject to appropriate conditions of confidentiality. This includes transferring personal information to USA or other countries for data processing and servicing. • Monitor and record my telephone conversations with you from time to time in order to train your staff and control your service quality. • Provide personal information to any organisation whose name, logo or trademark appears on this application or on the Card issued to me for marketing, planning, product development and research purposes, and seek from and exchange with such organisations personal information about me and the Supplementary Card applicant. I also agree that where I have provided you with information about another individual in this application form, I will make sure that the individual is aware of: – my supplying their information to you and the purposes why you have collected the information; – their ability to access that information in accordance with the Privacy Act (and advise you if they think the information is inaccurate, incomplete or out-of-date); and – the contact details of your Privacy Officer. American Express Australia Limited (ABN 92 108 952 085) ®Registered Trademark of American Express Company AE5797 AEQC SUPP_ONLINE 01/07 To American Express Australia Limited (“you” or “American Express”): By signing on the previous page, I request you to issue me with the Card specified in the application, and I declare that: • I understand that this is a Card offered, issued and administered by American Express Australia Limited; • The information I have given on this application is true and complete and I authorise you to check that information. I acknowledge that you rely on this information to consider this application; • I am financially solvent and able to pay all my debts as they fall due; • I understand that I will be liable for all charges on the Basic Credit Card and all Supplementary Card (s); and • You may produce this application or a copy or other reproduction of it as evidence of my application for the Card and my agreement to this Declaration. Invitation I invite you, your agents, Qantas Airways Limited and your preferred alliance organisations (including insurance companies) to use my personal information for marketing purposes. This includes contacting me by telephone, mail or email to discuss and agree any purchase of goods or services from an American Express company or your products and of Qantas Airways Limited or any third party providing products jointly marketed with American Express. I understand that I can call 1300 362 991 if I want to withdraw this invitation and remove my name from your marketing lists. Authority to American Express under the Privacy Act: To assess this application, and if it is approved, to establish and manage the Supplementary Card account, I understand American Express needs to: • Collect personal information about me in this application form and from other sources; and • Obtain my agreement in relation to the handling of my personal information. If I do not provide the information requested or give my agreement overleaf, I understand American Express may decline my application. The American Express Privacy Policy Statement sets out policies on management of personal information. In accordance with the Privacy Act, any person may access personal information about them held by American Express, and advise if they think it is inaccurate, incomplete or out of date. To arrange access to personal information, request a copy of the American Express Privacy Policy Statement or enquire generally about privacy matters, write to The Privacy