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Platinum Reserve Supplementary Credit Card Attn: ICSS Acquisition AMERICAN EXPRESS INTERNATIONAL, INC. Credit Cardmember Services Crawford Road P.O. Box 852 Singapore 911912 Application Form Postage will be paid by addressee. For posting in Singapore only. Please glue, seal and mail. (Do not staple). Supplementary Credit Card Application Form YES! I would like to apply for my Platinum Reserve Supplementary Credit Card(s). Annual fee of S$160.50 (incl. of GST) each; First 2 Supplementary Card(s) fee permanently waived. NAME OF BASIC AMERICAN EXPRESS PLATINUM RESERVE CREDIT CARDMEMBER Mr Mrs Miss Others (Please specify) Surname Given Name (As it appears in your NRIC/Passport) Nationality American Express Platinum Reserve Credit Card Account No. 3 7 6 2 1 Email* Declaration To: American Express International, Inc. I/We warrant that the above information is true and correct and by signing this form I/we ask that a Platinum Credit Card Account be opened for me/us and for Platinum Credit Card(s) be issued as requested (including renewal and replacement cards). I/We authorise you to verify the information in this application and to receive and exchange information about me, including requesting reports from consumer credit reporting or reference schemes. I/We authorise you and your affiliates to contact these sources for information at any time, to use information about me, including information from this application and from consumer credit reports, for marketing and administrative purposes and to share information with each other. I/We agree to be bound by the Terms and Conditions, which will accompany the Platinum Credit Card(s) when issued. If I/we have also asked for Supplementary Platinum Credit Card(s) to be issued, I/we understand that I/we shall be jointly and severely liable for all Charges incurred on any Supplementary Platinum Credit Card(s) to be issued. All transactions will be charged to my/our Account including all annual fees. I/We understand that American Express International, Inc., may decline this application at its sole discretion. I/We confirm that at the time of this application I/we am/are not undischarged bankrupt(s) and there has been no statutory demand, served on me/us nor legal proceedings commenced against me/us. By signing below, I/we acknowledge that I/we have agreed to the above declaration. Mobile No.^ Supplementary Applicant Singaporean & PR: Photocopy of NRIC (front & back) Foreigner: Photocopy of passport SUPPLEMENTARY CREDIT CARD 1 Supplementary Credit Cardmembers must be over 18 years old. Mr Mrs Miss Others (Please specify) PLEASE SIGN Please glue, seal and mail. (Do not staple). Surname Given Name (As it appears in their NRIC/Passport) Name to appear on your American Express Platinum Reserve Supplementary Credit Card (Please include surname) Date of Birth NRIC/Passport No. D D / M M / Y Y Nationality Relationship with Basic Cardmember Mobile No.^ Credit Cardmember Phone No. (Home# ) Address + Postal Code Gender Highest Qualification Supplementary Applicant 1 Date Supplementary Applicant 2 Date SUPPLEMENTARY CREDIT CARD 2 Supplementary Credit Cardmembers must be over 18 years old. Mr Mrs Miss Others (Please specify) Surname Given Name (As it appears in their NRIC/Passport) Name to appear on your American Express Platinum Reserve Supplementary Credit Card (Please include surname) Date of Birth D D / M M / Y Y NRIC/Passport No. Nationality Relationship with Basic Cardmember Mobile No.^ Phone No. (Home# ) Address + Postal Code Gender V3EDXX0BP1 * Your email address is mandatory as an alternate contact for us to reach you. You may also receive product and service offers at this email address. ^ Your mobile number is mandatory as an alternate contact option should additional information be required to process your application. Periodically you may receive product and service offers via SMS. # Your home number is an alternate contact option if we are unable to reach you through your mobile number. + Only if address is different from Basic Cardmember and please do not provide a P.O. Box Address Note: Please allow 7 working days for processing upon receipt of application. Please do not include payment with your application. Highest Qualification Please glue, seal and mail. (Do not staple).