Fill and Sign the Form Vm 2 Virginia Vending Machine Dealers Sales Tax Return

MEMBERSHIP REWARDS™ – request for points gift Please complete this form if you would like to gift your Points to another Membership Rewards Account. Name of Requestor Daytime contact number My Account details Membership Rewards or basic Card Account to be debited Points Card Number Expiry Membership Rewards Account Number Name on Card My family or friends’ account details Membership Rewards Account to be credited Points Membership Rewards Account numbers can be located: 1. Your Membership Rewards Statement. 2.  ogging onto the American Express L Online Service. 3.  ontacting American Express on C 1300 363 276. Membership Rewards Account Number Name of Account holder Amount of Points to be gifted In multiples of 1,000 Points to a maximum of 50,000 Points ,  understand a Tier Transfer Fee of $5 (including GST) per 1,000 Points applies to transfer Points between I Membership Rewards Choices to Membership Rewards Ascent. The fee will be billed my basic Card Account.  I acknowledge that I have read and understood the Points Gift Terms and Conditions (see next page). Signature 7 Date / / Subject to the Terms and Conditions of the Membership Rewards program. American Express Australia Limited (ABN 92 108 952 085). ® Registered trademark of American Express Company. AMEX2306_Points_RequestForm_V3.i1 1 AMEX2306 16/6/06 4:51:17 PM MEMBERSHIP REWARDS™ – TERMS AND CONDITIONS 1. A Points Gift is subject to these Terms and Conditions and the Membership Rewards Terms and Conditions. Words used in these Terms and Conditions have the same meaning as defined in the Membership Rewards Terms and Conditions. 2. You, the basic Cardmember, may request a Points Gift of between 1,000 Points to a maximum of 50,000 Points in multiples of 1,000 Points once each calendar year. A Points Gift may only be made between your Membership Rewards Program Account and the Program Account of another American Express Cardmember held in Australia. You may not request a Points Gift for more than your current Points balance. 3. We may decline a Points Gift request, at our discretion, including if your Card Account or any other account of yours held with us or any account held with us by the other Cardmember to whom you have requested we make a Points Gift, are not in good standing or are overdue. 4. A Points Gift request will be administered solely by American Express within 5 business days, and cannot be reversed or cancelled once made. 5. Points Gifting (a Points Gift request or a Points gift receipt) is not available on American Express Corporate Cards, Qantas American Express Cards, Qantas American Express Premium Cards, Qantas American Express Ultimate Cards and Card Accounts enrolled in Membership Rewards Spirit. 6. A Tier Transfer Fee of $5 (including GST) per 1,000 Points applies for a Points Gift from a Membership Rewards Choices Program Account to Membership Rewards Ascent Program Account. This fee will be billed to your Primary Card Account. 7. You agree not to request or accept any form of payment or item of value for a Points Gift. 8. Please note that a Points Gift may have tax implications for you. You should speak with your accountant or tax adviser for further information. Please mail to: Reply Paid 5148 American Express Australia Limited Sydney NSW 2001 or fax to: (02) 9271 1186 Please ensure that all details are completed before you return your application to us. Subject to the Terms and Conditions of the Membership Rewards program. American Express Australia Limited (ABN 92 108 952 085). ® Registered trademark of American Express Company. AMEX2306_Points_RequestForm_V3.i2 2 AMEX2306 16/6/06 4:51:17 PM