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CORPORATE SERVICES 

EXPENSE MANAGEMENT SOLUTIONS

American Express®

 Corporate Card

Individual ApplicationLimited Liability 

For Office use only

  Corporate ID HIR CAP APV DEC CX

Cost Centre Source Code

   V  e  r .   4 ,

   0   7   /   0   9

   F  o  r  m   -

   5

 

REAL BUSINESS. REAL SOLUTIONSSMRIVE SAVINGS | BENEFIT EMPLOYEES | 

www.americanexpress.co.in

American Express Banking Corp.

Cyber City, Tower C, DLF Bldg. No. 8 ,Sector - 25

DLF City Phase - II, Gurgaon - 122002, Haryana

8/8/2019 India - Ind Appl Prop Green LL v4 0709

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Declaration by the Individual:

I am applying to American Express Banking Corp. (“AEBC”) or an American Express

Corporate Card (“Corporate Card”) and agree to comply with the terms o the agreement,

which shall be sent along with my Corporate Card. I certiy that the inormation givenabove in support o my application is true and correct.

I acknowledge and consent to AEBC veriying the inormation with my employer and

any other sources that it may deem ft. I urther agree to provide any urther inormation

that AEBC may require to evaluate and approve my application. I also authorise AEBC to

confrm and exchange credit inormation about the company / applicant’s account rom

any source including but not, limited to Banks and Credit Bureaus. I authorise AEBC to

share and use my personal inormation (other than my fnancial inormation) provided in

this application and transaction details o the company account or availing any specialbenefts or services by the company/applicant under the Corporate Card and or any

marketing purposes. I acknowledge and agree that both AEBC, and the company shall

have access to all records arising out o usage o my Corporate Card account. I will be

liable or all charges incurred on it. I am also aware and agree that the company shall be

jointly and severally liable or charges, as provided in such conditions o the Corporate

Card account membership. I declare and undertake that in the event o any ailure to

comply with the prevailing Exchange Control Regulations issued by RBI, by me, I will beliable or any action under the Foreign Exchange Management Act, 1999 as amended,

rom time to time, and be debarred rom Corporate Card acility either at AEBC’s instance

or by the RBI. I understand that my Corporate Card will be issued at the sole discretion

o AEBC and i approved will be delivered to me within 15 working days o my application

being received by American Express.

Applicant’s Signature

DD MM YY

Applicant’s Name:

Declaration by the Company:

On behal o the company named in this application (“the Company”), I here by request

issuance o a Corporate Card to the individual named above and certiy that the named

individual is an employee o the company. I declare and undertake that a photocopy o

one photo identifcation (Valid PAN Card/Passport* /Driving Licence*/Electoral Card*) and

one proo o address (Latest Bank statement/ Utility Bill/ Ration Card) o all CorporateCardmembers including the applicant are available with the company and can be provided

to AEBC or verifcation purposes as and when required. I confrm that the inormation

given in this application orm is true and correct and that the company hereby agrees to

be bound by the American Express Corporate Cardmember Agreement which will be

sent along with the Corporate Card.

*Also valid or address proo.

Signature o Authorised Signatory and Company Seal

DD MM YY

Name o Authorised Corporate Signatory

Designation: Tel.:

Personal InformationName as desired on the card (Maximum 20 Characters including word space)

  (Please underline your amily name) 

Title Mr. Mrs. Ms. Other:(please speciy) 

Gender Male Female

Name o Applicant:  First

  Middle Last

Nationality: Date o Birth:DD MM Y Y

PAN/GIR No.:

Passport No.: Date o Expiry:

  DD MM Y Y

Driving Licence No.:

Residential Address:

City: PIN:

Tel.: Mobile:

Are you a current / past American Express Cardmember?

Yes No

I Yes, please give Card number(s)

3 7

 3 7

Company Name:

Corporate ID:

Work Address:

City: PIN:

Tel: Extn: Fax:

Ofcial E-mail Address:

Your Designati on:

Years with Company: Employee No.:

I you have worked or less than one year with the current

company, please also provide details o your previous employer:

Company Name:

Position in Company:

City: Tel.:

American Express® Corporate Card

Individual Cardmember Application

Limited Liability

Please mail completed application to:

American Express Banking Corp.Cyber City, Tower C, DLF Bldg. No. 8, Sector - 25DLF City Phase - II, Gurgaon - 122002, Haryana

Completion o all felds is mandatory 

Work Related Information

Additional Information

Address to which we should mail your Billing Statements:

Residence Work

Please sign me up or the Express Cash Facility*:

Yes No

*This request is valid and will be processed only i your company is enroled 

or this acility.

Financial Information

Gross annual taxable Income (Rupees):

(Please attach latest copy o TDS Form 16 / last income t ax return

acknowledged by ITO or latest salary certifcate rom employer) 

Details o your personal bank account:

Name o Bank:

Address:

City: PIN:

Tel.: Account No: