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58679 NZWEBSUPPPLAT 1205 12/20/05 8:46 AM Page 1 Supplementary Card Application Form Give your loved ones the PRIVILEGES OF PLATINUM MEMBERSHIP WITH A FREE SUPPLEMENTARY CARD Please turn over for details. American Express International (NZ), Inc. Incorporated in Delaware, USA. ®Registered trademark of American Express Company. NZWEBSUPPPLAT 1205 58679 NZWEBSUPPPLAT 1205 12/20/05 8:46 AM Page 2 To apply for a Free Supplementary Platinum Membership Rewards Credit Card, please fax your details and signed declaration to American Express on 0800 372 458 or mail it to Freepost 1588, American Express International (NZ), Inc., P O Box 4005, Auckland 1015. Basic Credit Cardmember’s Name Surname SC: 5X2168KØØ1 First Name Middle Initial My American Express Credit Card number is 3 7 7 4 4 5 Date of Birth D D/M M/ Y Y The Basic Cardmember has known the Supplementary Card Applicant for: 6-12 Months 12 Months or more Supplementary Applicant Details Mr Mrs Surname Ms Miss First Name Middle Initial Relationship to Basic Cardmember Home Address Postcode Home Phone No. ( ) Name to appear on Supplementary Credit Card Date of Birth D D/M M/ Y Y Important: The Basic Cardmember and Supplementary Card Applicant must read the information and sign below. TO AMERICAN EXPRESS INTERNATIONAL (NZ), INC.: 1. Basic Cardmember I request you to issue the Supplementary Card(s) specified in the application, and I declare that: • 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 and agree that I will be liable for all charges on the Supplementary Credit Card(s). This includes charges incurred at any time until each Card is cut in half and returned to American Express and no longer used; • you may produce this application or a copy or other reproduction of it as evidence of this application for the Supplementary Credit Card(s) and my agreement to this Declaration. 2. Supplementary Card Applicant Authority to American Express International (NZ), Inc. under the Privacy Act: I agree that, subject to the Privacy Act, you and your agents may do the following (and providing this application is approved, this agreement continues until such time as the Account is closed and any credit is repaid): • Obtain credit reports about me from credit reporting agencies to confirm my identity and to assess this application, and from a business that provides commercial credit worthiness information. • Verify with the LTNZ, driver’s licence and car registration information provided by me. • Exchange personal information with the organisation for marketing, planning, product development and informational purposes including for the administration of a rewards programme, if any. • Use personal information for marketing purposes. This includes putting my name and contact details on marketing lists for the purposes of customer research and offering me goods or services of an American Express company or of any third party acting on behalf of American Express, by mail, email or telephone or having your related companies do so directly. After approval of this application, I understand that I can call 0800 656 660 to remove my name from your marketing lists. I acknowledge my request may take 6-8 weeks to be processed. • 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 the USA or other countries for data processing and servicing. • Monitor and record my telephone conversations with you from time to time for training, quality control or verification purposes. If I believe that any information you hold about me is incorrect, I will write to your Privacy Officer at American Express International (NZ), Inc., PO Box 4005, Auckland 1015. Signature of Basic Credit Cardmember CONFIRMATION OF IDENTITY For your security and to meet legal requirements, we need to verify the identity of all Cardmembers. To assist in this process we require your NZ Driver’s Licence Number and/or Car Registration Number if held. NZ Driver’s Licence No. (Field 5a on your Licence) Declaration (Field 5b) Car Registration No. ✘ Date / / / / Signature of Supplementary Credit Card Applicant ✘ Date By signing above I/We certify that I/We have read and agreed to the above declaration with respect to Supplementary Cardmembership. Note: Your NZ Driver’s Licence No.and Car Registration No. will be verified with the LTNZ for confirmation of identity. Please note, American Express may need to contact you to gather additional information to verify your identity. The Basic Cardmember and Supplementary Card Applicant must read and sign the declaration on the right, then return to the address or fax number above. Please call 0800 888 025 if you require further supplementary applications. For Office Use Only PROD: 600 CIDS1: FEE: 4 CNTY: 884 PROC: 4 DEL: NOR