Fillable Printable Citibank Credit Card Application Form Sample
Fillable Printable Citibank Credit Card Application Form Sample
Citibank Credit Card Application Form Sample
®
Citibank Credit Card Application Form
Simultaneously with completing the present application form I hereby request a new credit card or the replacement of my existing credit card or a further credit card or the alteration of my credit limit.
I hereby request the following card: Citi Life
Telekom — Citibank Shell – Citibank Credit cards linked to Citi Gold status:
Platinum* Ultima**
* I declare and acknowledge that if my application does not meet the terms of Platinum credit card and I do not make a negative statement, simultaneously with completing and signing the Credit Card Application Form I expressly apply for Citi Life credit card. If
you do not wish to apply for Citi Life credit card should the Bank reject your Platinum credit card application and do not request the Bank to issue such a credit card to you, please mark as follows:
I do not apply for Citi Life credit card.
** Ultima credit card is a credit card applied for by the customer contacted by the Bank expressly with such offer and issued pursuant to the individual loan appraisal decision by the Bank.
Application ID:
To be completed by the Bank
Cf 09/21 E
5/1. page
Simultaneously with completing the present application form I apply for a Mobile Card to the above stated credit card if it can be applied for with respect to this type of credit card.
Amount of requested credit limit: HUF 100.000-190.000 HUF 200.000-390.000 HUF 400.000-590.000 Other amount: HUF_______________________________ (please state an amount that can be divided by 100.000)
By signing this Application Form I hereby acknowledge and accept that the Bank can increase the credit limit and/or the cash withdrawal limit linked to the Card semi-annually according to Section II.10 of the GTC, up to the maximum amount (HUF 3 500 000) of the
credit limit and/or cash withdrawal limit linked to the Card, on which increase of the credit limit and/or the cash withdrawal limit the account statement will inform me. If I do not wish to accept the increase of the credit limit and/or the cash withdrawal limit initiated
by the Bank, I can inform the Bank accordingly, by phone or in writing (mail, Citibank Online) within 15 days of the date of the written notification on the increase by the Bank. By signing this Application Form I hereby acknowledge and accept that the maximum
amount of the Advanced Loan on Phone service cannot be more than twelve times (12 times) the prevailing income of the Cardholder, maximum HUF 2.000.000.
Monthly amortisation instalment Amount of loan
Mortgage loan Overdraft facility
Automobile financing Credit card
Personal loan Other
Purchase loan Total
Credit combined
with life insurance
Personal details Please complete every red rows in ink and in block capitals!
Surname (as stated in identity card):
First name(s):
Name at birth:
Full name as you wish to have it displayed on the card (maximum 19 letters):
Sex: male
female Date of birth: year/month/day:
Place of birth:
Mother’s maiden name:
National of which country?:
Marital status: single
married divorced widow/er companion
Number of dependents:
Education: university college of higher education secondary school
vocational school primary school
Type of primary (1.) and secondary (2.) identification document: identity card
passport driving license residence card other:
Number of identification document: 1. 2.
Validity: 1. 2.
Date of issuance: 1. 2.
Issuing authority/country: 1.
2.
Permanent residence
1
If you reside abroad, you have to complete the declaration of customer residing abroad on page 3.
Postcode: City:
Address: No.: Floor, door No.:
Type of the document that verify residence (compulsory field to complete when the secondary
identification document is not the residence card):
Temporary residence
1
(To be completed only if different from permanent residence.)
Postcode: City:
Address: No.: Floor, door No.:
It is obligatory to complete fields marked with , other fields can be completed by consent of the applicant.
Your home: your property
your spouse’s property
family property
rented property
rented by your employer other
Since when have you lived in your current home (month/year)?
Home telephone number: 06 –
Primary mobile phone number
2,3,4
: 06 –
Compulsory field to complete!
Additional own mobile phone number
2
: 06 –
Days/hours on/during which you may be called:
Primary e-mail address
2,4
:
Compulsory field to complete!
I acknowledge that by completing the primary e-mail address field I expressly request the Bank to provide the
electronic account statement service within the scope of Citibank Online service instead of sending paper based
Account Statement of the credit card account. I acknowledge that the precondition of the service is the use of
Citibank Online Service (CBOL). I acknowledge that later I may change the estatement settings, modify the method
of delivery or delete the enrollment of e-statement service and I may ask printed statement instead of e-statement.
Additional own e-mail address
2
:
Mail address Permanent residence
Temporary residence Work address
(We are unable to accept post office box addresses!)
1
I hereby accept that the Bank may inform me of its personalized offers, products and services by way of direct marke-
ting letters. Yes No
2
I hereby accept that the Bank may send information regarding its products and services to this e-mail address and/or
mobile telephone number. Yes No
My present consent/consents is/are voluntary and was/were granted in the light of the relevant information. The last
paragraph of the statement on the back of page 5/1 provides for issues related to data management.
3
I hereby accept that, based on the Code of Conduct also signed by Citibank and Section 39, subsections (5) and (6) of Act
LXXXV of 2009 on Money Transaction Services, the Bank is entitled to send SMS text messages concerning my Contract
to the mobile telephone number stated.
4
I hereby acknowledge that the Bank sends to this mobile phone number, mail address or e-mail address provided all mails
security codes and notices related to all the products and services of the Bank. The mobile phone number, mail address and
e-mail address stated in this application override the e-mail address, mail address and mobile phone number previously
provided with respect to any contracts concluded with the Bank or to the use of other Service pursuant to the GBC.
Employment details Please specify whether you are : employee
individual entrepreneur owner of business association pensioner
other
Business tax number:
(To be completed only if you are an individual entrepreneur or owner of a business association.)
Employer’s name:
Current occupation:
Sector of operation:
(e.g. trade, financial services, state administration, etc.)
Employer’s address: Postcode: City:
Address: No.: Floor, door No:
Telephone: 06 –
E-mail address:
Since when have you worked for your current employer? / Since when have you had your current business?
Regular monthly net income:
By signing this Application Form, fully aware of my criminal liability, I hereby state that to the best
of my knowledge my employer has paid the charges linked to wages and salaries, as required by the
relevant legal regulations, on the income transferred to my bank account.
Other source of income:
Previous employer’s name:
How long did you worked for your previous employer (month-year):
Bank contacts Do you have any product with Citibank Europe plc. Hungarian Branch Office? Yes
No
Your regular payment liabilities with other financial institutions
Citibank SMS Alerting service
I hereby accept that unless I make a negative declaration with respect to the Citibank SMS Alerting Service, by
completing and signing the present Application Form, I expressly request the Bank to provide the Citibank SMS
Alerting Service on the basis and under the terms and conditions of the GTC, GBC and the Conditions of Interest
and Charges with respect to the message types listed on the back of Page 5/1 of this Application Form, in the
form of SMS text messages or e-mail. If you do not wish to request the service, please state: I do not request
the Citibank SMS Alerting service
Citibank Online and the Citibank Mobile Banking services
The Bank makes available the Citibank Online and the Citibank Mobile Banking services to all Cardholders. The
condition of actual application and use of Citibank Online and Citibank Mobile Banking are registration by the
Cardholder for the Citibank Online service at the web site of the Bank and accepting the terms applicable to the
service during registration. I am aware that the CBOL Service is considered an electronic payment instrument.
I have acknowledged the information overleaf concerning the management of personal data by the
Bank and its Partners and hereby consent thereto. Yes
No
Please remember to sign here!
Main Cardholder’s signature:
Completed by banker/credit mediator!
Image on identification document is identical to the applicant
Signature on identification document is identical to the one on the Application Form.
The undersigned, banker’s/credit intermediary’s name (company name) and code:
and intermediary’s mailing address (head office):
as the employee / contracted intermediary of Citibank Europe plc. Hungarian Branch Office (Szabadság tér 7., Budapest
H-1051, Cg. 01-17-000560; hereinafter: Citibank), legal representative of Citibank Europe plc. (1 North Wall Quay, Dublin 1.,
Ireland) by signing this statement I declare under penalty of perjury that I identified the person submitting this credit card
application in accordance with the provisions of Act CXXXVI of 2007 on the Prevention and Combating of Money Laundering
and Terrorist Financing, the requirements of the General Business Conditions of Consumer Banking of Citibank and the Anti-
Money Laundering policies of Citibank. I also declare that the personal data shown on this application form are fully identical
to the data stated in the personal identification document presented by the applicant to me.
Signature of banker/intermediary:
The credit intermediary acts on behalf of Citibank Europe plc. Hungarian Branch Office.
The present application form consists of five sheets and carries a duplicate copy.
Date: (place), day month year
I hereby submit my application for a credit card issued by Citibank Europe plc. (registered offices: 1 North Wall Quay, Dublin 1, Ireland, corporate registry nr.:132781, issuer and date of operating license: Central Bank of Ireland, 01
May, 2001), acting through Citibank Europe plc. Hungarian Branch Office (registered offices: H-1051 Budapest, Szabadság tér 7.; corporate registry nr.: Cg.01-17-000560) (hereinafter: Bank) the type of credit card applied for is stated
on page 5/1 and/or for a Mobile Card to the credit card herein applied for if it is available for the credit card applied for and I do apply for it. By signing the present Application Form I hereby declare that I have familiarized myself
with the provisions of the General Business Conditions of Consumer Banking (GBC) of Citibank Europe plc. Hungarian Branch Office, the General Terms and Conditions of Citibank’s HUF-based Individual Credit Cards (GTC) and the
Citibank Conditions of Credit Card Interests and Charges (Conditions of Interests and Charges), which the issuer Bank will place at my disposal simultaneously with the receipt of the credit card and/or Mobile Card. The provisions
of the above documents govern the main card, all supplementary cards and the Mobile Card linked to the credit cards. The main card, the supplementary card and the Mobile Card applied for with respect to them hereinafter are
jointly referred to as credit card.
By the signing of the present Application Form I hereby declare that the Banker or the credit intermediary has provided verbal information on the maximum and minimum amount of the credit facility, the PTI (payment to income
ratio), the way of calculation of interests, the APR, the amount and the frequency of the instalments, the available tenors of the credit. If a credit intermediary is involved, I have also received the information on the right of
representation of the credit intermediary and the fees, costs and other payment obligations payable to the credit intermediary. I have accurately read and understood the annexes of this Application Form.
I hereby acknowledge and accept that, by virtue of the validation of the credit card, the GBC, the GTC and the Conditions of Interests and Charges will take effect, and validation simultaneously constitutes express and full acceptance
of the provisions of the GBC, the GTC and the Conditions of Interests and Charges previously made available. I hereby accept that the GBC, the GTC and the Conditions of Interests and Charges as in force may also be viewed in the
Bank’s branches. Fees, interests, costs applicable to certain credit card types and grades and the Average Percentage Rate (APR) of credit cards are stated in the prevailing Conditions of Interests and Charges. I hereby accept
that if, at this point in time, I do not wish to use the automatic Citibank Online Internet Banking and Citibank Mobile Banking service (hereinafter: CBOL service) or the setting of the Citibank SMS Alerting (CitiAlert) service, I do not
exclude myself from the use at any time in the future of either of the said services, provided that I state my request for either service in a Citibank branch, via the CitiPhone Telephone Customer Service or, for the setting of the
CitiAlert service, via the Citibank Online interface. I can state my request for Citibank SMS Alerting Service in a Citibank branch, via the CitiPhone Telephone Customer Service or via Citibank Online. The Bank makes available the
Citibank Online and the Citibank Mobile Banking services to all Cardholders without the obligation of use. The condition of actual application and use of Citibank Online and Citibank Mobile Banking are registration by the Cardholder
for the Citibank Online service at the web site of the Bank and accepting the terms applicable to the service during registration.
I hereby accept that if I did not make a negative statement with respect to the Citibank SMS Alerting service, the request for the Citibank SMS Alerting service shall relate to the primary mobile telephone number and primary
e-mail address stated in the present contract and to the credit card issued on the basis of the present contract, in respect of the message types available at the time of the application as follows. I may request changes to
the settings at any time following the placement at my disposal of the Citibank SMS Alerting service via the CitiPhone Banking telephone customer service or if I have the CBOL service at my disposal, I myself may change the
settings. By default SMS messages and e-mail will be sent to inform you on transactions effected with your credit card, the due dates of repayment, the renewal of your card; only e-mails will be sent to inform you on incoming
credit transfers in addition to these transactions. The Citibank SMS Alerting service is not an electronic payment instrument. The SMS and e-mail messages sent as part of the service only serve information purposes and do not
qualify as accounts or account statements. The terms and conditions attached to the service are stated in the General Business Conditions of the Retail Banking Services of the Bank. By giving the primary e-mail address on the
cover the Main Cardholder expressly requests the Electronic Account Statement Service also, that is after becoming familiar with the applicable General Terms and Conditions the Main Cardholder expressly requests the Bank to
make the Electronic Account Statement Service available in the framework of the Citibank Online Service instead of sending the paper based Account Statement related to the credit card account and acknowledges that the use
of Citibank Online is the precondition of the Service. The Bank assumes no liability for any error in the Internet connection. The form and content of the electronic account statement are identical to the form and content of the
paper based account statement for the same period, except that the electronic account statement is not considered accounting document pursuant to the accounting requirements. At request the Bank makes the paper based
account statement available to the Main Cardholder anytime.
I hereby further accept that the Bank is entitled to grant or to refuse my application for the credit card and/or Mobile Card without stating its reasons. I declare that I acknowledged and accept that rejection by the Bank of my
credit card application constitutes rejection of Mobile Card application also. I hereby further accept that the Bank is entitled to grant or to refuse my/our application for a credit card without stating its reasons. By completing
the resent Application Form, I hereby declare that all data items stated by me in the documents forming part of and related to the present application are true, accurate and complete. I hereby declare that I shall supply true and
correct data to the Bank until the payment in full of the debt arising from the credit card contract, and hereby expressly accept the following and authorize the Bank:
a) to manage, store and process all my personal data supplied by me upon the submission of the application for the given Service or during the term of the contract in writing, verbally or in any other manner as well as all my
personal data disclosed to the Bank in any other manner in compliance with the legal rules regarding data protection, within the relevant statutory period of limitation or for the period of time determined in any other mandatory
statutory regulation, in the interest of the enforcement of the rights and the fulfillment of the obligations arising from the contract, for risk analysis and risk minimization purposes, in the interest of enabling the Bank to inform
me directly of the services provided by it (unless I expressly objected to the latter) and for the purposes determined in other parts of the contract;
b) to verify the correctness of the data supplied by me in compliance with the relevant legal rules;
c) to process and to manage, as part of its work processes, my data generated/managed in connection with the contract within the units of Citigroup in compliance with the legal rules regarding data protection (drafting of
statistics, printing of bank cards, printing of account statements), to forward and to share the same for the purposes of processing and management to and with other units forming part of the Citibank/Citigroup Group, whether
in Hungary or abroad, and further to disclose the said data to the Bank’s banking and/or investment agents and/or to insurance agents in contact with the Bank for the purpose of the sale of the Bank’s services and the settlement
related thereto;
d) to disclose to third parties data relating to my person in connection with services provided for me for the purpose of the printing of postal orders, bank cards and bank account statements, consumer research conducted with
respect to the Bank’s products, the enforcement of the Bank’s due receivables and data management and processing in conjunction with the above;
e) if I am a taxpayer in the United States of America (hereinafter „USA”), to file the report under the tax laws of the USA with the competent USA authorities, and in this context, I hereby exempt the Bank from its obligation of
confidentiality;
f) if I am a taxpayer in the United States of America (hereinafter „USA”), to file the report under the tax laws of the USA with the competent USA authorities, and in this context, I hereby exempt the Bank from its obligation of
confidentiality.
I hereby accept and agree that
a) the Bank may process any of my personal data disclosed to the Bank in any Citibank unit in the following countries in compliance with the Hungarian data protection laws: Germany, Singapore, Poland, Greece, United States
of America, United Kingdom, India, United Arab Emirates, and the Philippines. I hereby accept and agree that any data forwarding to the member states of the European Union shall be construed as data forwarding within the
territory of the Republic of Hungary.
b) in the case of data managed abroad the Bank also allows me to exercise the rights related to my personal data as determined in Act CXII of 2011 on Informational Self-Determination and Freedom of Information.
c) based on the rules of law, the Bank may be entitled / obliged to supply data in certain instances which will not constitute a breach of confidentiality.
I hereby accept that the Bank will state in the Conditions of Interest and Charges the range of outsourced activities, as defined in Act CXII of 1996 on Credit Institutions and Financial Enterprises, and the names of the entities engaged
in such outsourced activities. The Bank will additionally provide information on its Internet website on any third parties that may, as part of their other activities pursued on behalf of the Bank, manage, store or process my data.
The Cardholder shall notify the Bank in writing, via CitiPhone Banking or Citibank Online if there is a change in his/her mobile telephone number or e-mail address, in such a way that the written notice shall be received by the Bank
before the change takes effect. Until due notification, the Bank shall continue to send messages to the mobile telephone number or e-mail address stated earlier. No responsibility shall lie with the Bank for any loss that may so arise.
I hereby accept and grant my consent to the following
- in the interest of concluding the present contract and preventing the unauthorized use of identity cards, the Bank shall verify, based on the data supplied by the Ministry of the Interior, Central Records and Election Office, the
personal data stated by me and shall determine the reason for and date of any possible removal from the records. If, based on Section 2, subsection (1) of Act LXVI of 1992 on the Registration of the Personal and Residence Data
of Citizens, I exercise my right to have my data blocked, by virtue of my present declaration, I also authorize for a single instance the disclosure of the data blocked.
- the Bank shall disclose to the international card company and the merchant network the customer data necessary for the entry into force of credit card cancellations in the network of the international card company and I
hereby exempt the Bank from confidentiality.
- the Bank shall record the conversations conducted as part of the CitiPhone Banking service and may use the recordings in disputes covered by such conversations as evidence.
- the Bank may install cameras on its own premises open to customers, in ATMs and on the premises of ATMs which may make video recordings of me, and the Bank may use such video recordings as evidence for the settlement
of any dispute.
I hereby accept that, in the case of insurance services requested with the mediation of the Bank, the Bank shall be entitled to hand over to the given insurer data related to the conclusion and registration of the insurance contract
and the insurer’s service. Data management may be necessary for the purpose of the conclusion and amendment of the insurance contract, the maintenance thereof in the insurer’s portfolio and the assessment of claims arising
from the insurance policy, or may serve any other purpose determined by law.
I hereby additionally accept that if the present contract is not concluded subsequent to the submission of the present service application, I may demand the return of any documentation containing my personal data handed over
to the Bank within eight days of the frustration of the conclusion of the contract, on the basis of which the Bank shall return such documentation. Following the time limit available for demanding the return of documentation
containing personal data, the Bank shall destroy the documentation containing such data, unless the Bank stores, manages and processes such documentation for direct marketing purposes in full compliance with the data
protection regulations set forth in the relevant legal rules. Bank’s data management identification number: 344-0002.
I am aware that at my request the Bank and its partners (partners participating in the Citi Life program, or Shell Hungary Zrt. or Magyar Telekom Zrt.) provide information within 30 days on the data managed by them and on data
processed by the data processor mandated by the Bank, the purpose, legal basis, period of data management, the name, address (registered seat) of the data processor and its activities related to data management, furthermore
on the persons and purposes for which they receive or have received the data. This information is provided free of charge if in the same year I have not yet submitted a request for information to the Bank on the same subject.
Otherwise the Bank reserves the right to define an amount to be paid to reimburse the Bank for its costs. I am also aware that I can protest the management of my personal data if (i) management (forwarding) of personal data
is necessary exclusively to enforce the legal right or legal interest of the Bank or the entity receiving the data, except if data management is required by law; (ii) personal data is used or forwarded for the purpose of direct busi-
ness acquisition, public opinion poll or scientific research; (iii) the right to protest is allowed to be exercised by law. Furthermore I can go to court and report the case to the National Data Protection and Freedom of Information
Authority if my rights are violated.
I am aware that I may announce in person, in any bank branch or credit center, in writing, via the CitiPhone Banking customer service and electronically via the relevant menu item of the Citibank Online customer service if I do
not wish to receive information concerning the personalized offers, products and services of the Bank and/or the Bank and its partners participating in the Citi Life program or of Shell Hungary Zrt. or Magyar Telekom Zrt. by way
of direct marketing. I may issue a waiver to the above effect at any time, unconditionally, without stating my reasons, free of charge. However, also in the event of a request to the above effect, the Bank shall be obliged to send
information required under the present contract or the rules of law to me.
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Cf 09/21 E
5/1. back side
To be completed by the Bank
12345678
Customer ID:
Source code:
Program ID 2:
Banker/
Location code: 1.
2.
3.
Statements
Citi Life credit card related statement
I acknowledge and accept that the Bank informs me on the redemption of Citi Forints collected with the Citi Life credit card in an advice sent to my Primary e-mail address and/or Primary mobile phone number herein stated.
Simultaneously with signing the Application Form I acknowledge and accept the Citi Life General Terms and Conditions and that Citi Forints can be collected in line with the provisions of the Citi Life Program only.
Telekom – Citibank credit card related statement
I acknowledge and accept that the Bank informs me on the redemption of Citi Forints collected with the Telekom-Citibank credit card in an advice sent to my Primary e-mail address and/or Primary mobile phone number herein stated.
Simultaneously with signing the Application Form I hereby acknowledge and accept the Telekom-Citibank General Terms and Conditions and that Citi Forints can be
collected in line with the provisions of the Telekom-Citibank Program only.
Shell-Citibank credit card related statement
Simultaneously with signing the Application Form I hereby acknowledge and accept the Shell-Citibank General Terms and Conditions and that Citi Forints can be collected
in line with the provisions of the Shell-Citibank Program only.
Statement on data management
Simultaneously with signing the Application Form I hereby acknowledge and consent to the management, storage, processing and forwarding to each other by the Bank and its contractual Partners of my data stated on this
Application Form during the term of their co-operation and while my credit card agreement is in force by ensuring my rights stipulated in Act CXII of 2011 on Information Self-Determination and Freedom of Information as follows:
- For Citi Life credit card data managed, stored and forwarded to each other by the Bank and the Partners participating in the Citi Life Program for the purpose of Citi Forint collection, use and settlement: name, address, phone
number, e-mail address and Citi Life card number, information related to purchases made with the Citi Life card and registered Citi Forints;
- For Telekom-Citibank credit card data managed, stored and forwarded to each other by the Bank and Magyar Telekom Nyrt. with respect to the application of Telekom-Citibank credit card and upon credit card approval by
the Bank for checking data for contracting: name, date of birth, sex, name of mother, citizenship, address, phone number, e-mail address, number of Kapcsolat card, information on the type of credit card, information on
spendings made with the credit card;
- For Shell-Citibank credit card data managed, stored and forwarded to each other by the Bank and Shell Hungary zRt. (or its third party agent*) for checking data: name, address, office and home phone number, mobile phone
number, e-mail address, credit card number, information on credit card type, information on spendings with the credit card.
* The list of such third-party business organizations as at any time may be requested from the SMART Customer Service. I am aware that I may prohibit such data management via the Bank as set forth in the present declaration or via Shell Hungary zRt. on the customer service
telephone number: +36-1-436-5000 (8.00 a.m. and 6.00 p.m. on business days)
Statement on market research and direct business acquisition
I hereby consent to and authorize Magyar Telekom Nyrt. in case of Telekom-Citibank credit card application, Shell Hungary Zrt. in case of Shell-Citibank credit card application, partners participating in the Citi Life program
in case of Citi Life credit card application to manage and store my data stated on the Application Form, information on spendings made with my credit card during the term of co-operation with the Bank for the purpose of
market research and direct business acquisition, to send information on their personalized offers, products and services by way of direct marketing and advice sent to my Primary e-mail address and/or Primary mobile phone
number. I state that my consent/consents is/are voluntary and is/are given based on appropriate information received. ). The last paragraph on the back of page 5/1 of this Application Form provides for issues related to data
management. Yes
No
I state that my consents to sending the above information and data management are the voluntary and clear expression of my relevant will that is based on the receipt of proper information as stated in the last paragraph
on the second page of the Application Form, including information received on my rights and legal remedies available to me related to data management and with which by signing this credit card Application Form I provide
unequivocal consent to the management of personal data related to me.
Date, (place), day month year
Simultaneously with signing the Application Form I hereby acknowledge and accept the provisions of the statements on data management, market research and direct business
acquisition related to the Citi Life or Shell-Citibank or Telekom-Citibank credit card and the General Terms and Conditions applicable to the credit card applied for and accept the
above statements as unconditionally binding on me:
Credit card related authorization for the execution of standing orders
I hereby authorize the Bank to execute standing order in the amount of the due credit card debt in my Forint current account number:
– – kept by the Bank.
I request the monthly Minimum Payable Amount by settlement period) to be paid with standing order. I acknowledge that related to this standing order anytime later I can change the number of the current account stated and
the amount to be transferred..
Cf 09/21 E
5/2. page
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Customer’s signature
Customer’s signature
Standard Travel Pack and Ultima Travel Pack – hereinafter jointly: Travel Pack (with travel insurance) – declaration of insured party
I acknowledge that the age limit of insurance application is identical to the age limits of credit card and debit card application. For the Supplementary Card Holder insured persons the minimum age is 14, the age of Children insured
persons can be between 6 months and 18 years, except for regular student children in regular schools whose maximum age limit is 23 years.
I acknowledge that Travel Pack provides insurance for all my trips abroad not longer than 60 days (e.g.in case of accident, illness or damage to luggage) in line with the terms of insurance as long as I have an active and valid credit
card. The Travel Pack contains travel insurance and various discounts related to purchases.
I acknowledge that Travel Pack is linked to my credit card free of charge and automatically if I apply for Platinum Card (Standard Travel Pack) or for Ultima credit card (Ultima Travel Pack).
In the case of the application for any other type of credit card (Citi Life, Telekom-Citibank, Shell-Citibank) Travel Pack has to be applied for separately, either by completing the appropriate field of this statement or subsequently,
in the manner stated in the terms of insurance. I undertake to pay an annual service fee of HUF 4 990/year/person for using Standard Travel Pack, the annual fee of the Ultima Travel Pack is HUF 9 990/year/person. The terms of
insurance can be found in the document entitled ’Citibank – Terms of Travel Insurance’ that was made available to me simultaneously with Travel Pack application or is to be mailed by the Bank in case of subsequent application
and is also available in branches.
Details of discounts can be found at the website www.citibank.hu. I am only able to avail myself of the discounts attached to the Travel Pack in partner offices in the event of payment by a credit card issued by the Bank.
The general waivers stated in the insurance terms and conditions entitled ‘Citibank – Terms of Travel Insurance’ (e.g. damage events caused by acts of terrorism, illness already existing prior to the conclusion of the insurance
contract, willful acts, accidents arising from hazardous sports, sun stroke) shall relate to all services to be provided by the insurer. Further waivers relating to the given insurance service may be found under the detailed description
of the insurance events in the terms of insurance.
I hereby authorize the Bank as the contracting party to the insurance agreement, AIG Europe Limited Magyarországi Fióktelepe (Váci út 76, Budapest, H-1133) as the insurance company providing the service and TravelGuard (Europe
Assistance Magyarország Kft., Dévai u. 26-28, Budapest, H-1134, tel:+36-1-501-1501) as the company providing the assistance services to manage my data related to the insurance service, to the extent necessary for the fulfillment
of the obligations and enforcement of rights under the insurance agreement, throughout the term of the insurance policy and, if necessary, to forward the same to companies abroad forming part of the AIG Group, subject to the
rules on forwarding data abroad, to AIG Inc. U.S.A. and to the company(ies) under its direct or indirect control. I may contact the head of AIG Europe Limited Magyarországi Fióktelepe (Váci út 76, Budapest, H-1133, tel: +36-1-801-
0801, fax:+36-1-801-0899) with any remarks concerning the insurance service. The basic condition of the insurance service is that damages are to be reported without delay to Travel Guard at phone number +36-1-501-1501 that
can be called 24 hours a day. Claims related to luggage and other claims not reported to Travel Guard are to be submitted in writing to AIG Europe Limited Magyarországi Fióktelepe (Váci út 76, Budapest, H-1133) within 30 days of
arriving home.
In case of Citi Life / Telekom-Citibank / Shell-Citibank credit card application I acknowledge the following:
• In the event of a Travel Pack application, I hereby accept that the Bank may debit my credit card account with the amount of the service fee payable by me at the due date thereof. The Travel Pack shall be automatically renewed
upon the expiry of the period of one year. Simultaneously, the Bank shall repeatedly debit the annual service fee to my card.
• For the purpose of obtaining a purchase discount, in addition to payment with the credit card/bank card, the Emergency Assistance Card is to be presented to the partner office staff member.
• In case of insurance applied for by signing this declaration the insurance takes effect from 00:00 hrs. of the day following card activation/during the term of the credit card agreement, if the insurance is applied for subsequently,
the insurance takes effect from 00:00 hrs. on the day following application, purchase discounts related to the Travel Pack can be used from the time of receipt of the Emergency Assistance Card that is sent following application.
• In case of credit protection applied for simultaneously with credit card application the insurance legal relationship can be terminated with immediate effect within 30 days of credit card activation. Following the end of the above
period of 30 days the credit protection is in force until the credit card due date following termination in case of Travel Pack applied for with respect to the main card, while the Citibank Travel Pack applied for supplementary cards,
debit cards and relatives is valid until the 15th of the month after termination. If no damage occurred, the service fee corresponding to the unused part will be repaid.
I hereby state that the insurance terms and conditions as in force were placed at my disposal, I have read and understood them, and by signing the present Application Form, I hereby accept the provisions thereof and the terms
and conditions set forth above as binding on me. I hereby acknowledge that in case of termination of the credit card agreement for any reason the Travel Pack shall simultaneously cease to have effect with respect to my person,
following which my status of insured party shall also cease. With respect to the Travel Pack I hereby authorize the insurer to obtain and keep records of data with respect to my state of health or directly related to and essential
for the conclusion and amendment of the insurance contract, the maintenance thereof in effect and the assessment of claims arising from the insurance contract, to use the same within the said range and for other purposes
determined in Sections 157 (1) and (6)-(7) and Section 159 (1) of Act LX of 2003 on Insurers and Insurance Activities to forward the said data to those authorized thereto. I hereby simultaneously exempt the persons and organizations
keeping records of such data on the basis of statutory authorization (e.g. investigating authorities, patient care service providers keeping health care and personal data, the institutions of the health care system, attending
physicians, general practitioners and all health care institutions, physicians, pharmacists, alternative practitioners and other persons involved in my medical treatment which or who have to date treated me as patient, as well as
the National Health Care Fund and social security payers) from their obligation of confidentiality.
The insurer may manage data directly related to my state of health during the term of the insurance legal relationship and as long as claims may be enforced in connection with the insurance legal relationship. The insurer shall
delete all data related to its customers, former customers and unconcluded contracts, in the case of which the purpose of data management has ceased or for the management of which the insurer does not have at its disposal
the consent of the person concerned or for the management of which there are no statutory grounds. The Insurer shall treat data that may have come to its attention as insurance secrets and shall keep confidential such secrets
without any time restriction.
For the purpose of the travel insurance the supervisory authority of the insurers: National Bank of Hungary (Krisztina krt. 39., Budapest, H-1013). If regulations on consumer protection are violated you can turn to the National Bank
of Hungary (Krisztina krt. 39., Budapest, H-1013), you can go to court or turn to the Financial Arbitration Board (1525 Budapest, BKKP, POB 172.) with respect to legal disputes and the resulting legal effects of contract execution,
validity, termination and breach of contract;. The Bank’s telephone customer service shall provide information on any insurance related issues at telephone number +36 1 288 88 88. I may initiate the termination of the Travel Pack
(except for the Travel Packs linked to the Platinum and the Ultima credit card) in writing, addressed to the Bank (Váci út 35., Budapest, H-1134 and Budapest H-1367, POB. 123.), or at telefax number 06-40-200-300.
We wish to inform you that you may request the Travel Pack for your relatives determined in the insurance terms and conditions via CitiPhone Banking (+36 1 288 88 88). The Travel
Pack (except for the packs linked to the Platinum and the Ultima credit cards) is an optional service and does not in any way affect the assessment of your credit card application.
I hereby request the Citibank Travel Pack: Standard Travel Pack
Ultima Travel Pack
Application to change (replace) the type of the existing Citibank credit card
I hereby acknowledge and consent that if I satisfy the conditions of the credit card type marked on Page 1. of the Application Form requested (newly requested credit card) to replace the existing Citibank credit card, the credit assessment
relating to the newly requested credit card is closed with a positive result and the contract related to the newly requested credit card enters into force, as of the date of the approval by the Bank of the application*, any spending on
and fees, interests and charges attached to my credit card number__________________________________________ shall be debited from the credit limit attached to my newly requested credit card and any payments made subsequent
to the acceptance by the Bank of the application shall be settled in my newly requested credit card account. I hereby state that I have read the Citibank Conditions of Credit Card Interests and Charges (Interests and Charges), the
General Terms and Conditions of Citibank’s HUF-Based Individual Credit Cards (GTC) and the General Business Conditions of Consumer Banking Services of Citibank (GBC) valid at the time of credit card application approval by the Bank
and expressly accept the newly requested credit card to be governed by the provisions of the Interests and Charges, the GTC and the GBC.
I hereby acknowledge that if related to my existing credit card I hold a Mobile Card, the Mobile Card will be blocked jointly with the existing credit card. Furthermore, I acknowledge that the Travel Pack applied for related to my existing
credit card, both with respect to my person and the Supplementary Card Holder(s)/relative(s) stated related to the existing credit card, will cease to exist, the Main Card Holder can apply for Travel Pack linked to the newly requested
credit card by completing and signing the ’Travel Pack declaration of insured party’ document, against a separate fee stated in the Interests and Charges valid at the time of application approval by the Bank. If the existing credit card
is replaced with a Platinum or Ultima credit card, the Travel Pack linked to the existing credit card will cease to exist both with respect to my person and the Supplementary Card Holder(s)/relative(s) stated related to the existing credit
card and the Travel Pack (in the case of Platinum credit card the Standard Travel Pack, in the case of Ultima credit card the Ultima Travel Pack) will be available with respect to me as Main Card Holder free of charge as of the date of
activation of the newly requested credit card.
If you apply for Travel Pack in respect of the newly requested credit card and request Travel Pack to be offered to the Supplementary Card Holder(s) and/or relative(s) determined for the existing credit card in the newly requested credit
card also, please complete the following Statement:
Hereby I request Travel Pack in respect of the newly requested credit card to be offered to the persons who are the same persons as the insured persons/beneficiaries defined for the existing credit card. I hereby acknowledge that the
fees stated in the Interests and Charges valid as of the date of approval of this application by the Bank will be charged to the persons stated as insured persons/beneficiaries. I also state that the insured persons/beneficiaries are the
same persons as the persons stated as Supplementary Card Holder(s) and/or relative(s) in respect of the existing credit card and there was no change to their personal data (name, address).
I request
I acknowledge that all other insurance services requested with respect to the existing credit card will be transferred to the newly requested credit card and as of the date of activation of the newly requested credit card such insurance shield(s)
linked to the earlier credit card remain(s) in force unchanged.
Any direct debit orders given with respect to the existing credit card that were set to the debit of the credit card account shall be automatically transferred to the newly requested credit card following activation by the customer. If you do
not request the automatic transfer of the direct debit orders please state this on the form entitled ‘Authorization Regarding Execution of Direct Debit’ or following activation of the newly requested credit card via the Citibank Online service or
the CitiPhone Banking telephone customer service (telephone: +36 1 288 88 88). Any direct debit orders submitted to the debit of a bank account kept with another bank to settle credit card debts shall not be automatically transferred to the
newly requested credit card. If you request such direct debit orders to be transferred, please state this in a newly completed form entitled ‘Authorization Regarding Execution of Direct Debit’ or following the activation of the newly requested
credit card via Citibank Online service or the CitiPhone Banking telephone customer service (telephone: +36 1 288 88 88).
I hereby acknowledge and accept that the type of the existing credit card is changed (replaced) by the Bank mailing to me, following receipt of this request and the Application Form, subject to the result of the loan appraisal, the newly
requested credit card. The existing credit card can be used to make cash withdrawal and purchase transactions subject to the following but not later than 30 days after credit appraisal. I hereby acknowledge and accept that simultaneously
with the validation of the newly requested credit card but not later than 30 days after the replacement the existing credit card will be blocked. The exact time of card replacement depends on the credit assessment by the Bank and therefore
it may take place at any time. I shall take this circumstance into consideration in planning cash withdrawals, purchases with my existing credit card subsequent to the date of this declaration. Furthermore, I acknowledge that the alteration of
the credit card type shall qualify amendment of the contract in force between me and the Bank.
I, the undersigned, hereby confirm that in the event of the completion of any other declarations relating to the credit card application and the declarations relating to the Consent to replace credit card type I accept the contents thereof.
Date: (place), day month year
* The date of the notification letter by the Bank on acceptance shall qualify approval by the Bank.
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Customer’s signature
Customer’s signature
Notice to retail customers about the Central Credit Information System
Dear Customer, In accordance with Act CXXII of 2011 on the Central Credit Information System (hereinafter: CCIS Act), and especially pursuant to the provisions of Articles 9 (2) and 15 (1) thereof, the Bank herewith provides the following information to you regarding the rules applicable
to the Credit Information System, especially with regard to the purpose of data recording and to your rights.
Please read the information and the publication entitled “Information from the Hungarian Financial Supervisory Authority for private individuals regarding the Central Credit Information System” constituting an annex thereto carefully, and if you are present in person, please listen
to the oral explanation of our employee, and confirm your acknowledgment that such has taken place by signing a copy of this Notice.
Declarations related to the Central Credit Information System
In light of the information provided regarding the Central Credit Information System, unless statement to the contrary is made, I hereby state:
• I grant my consent for the Bank to retrieve from the CCIS and store, for the purpose of assessing my current loan application, the full range of my reference data relating to the „positive debtor list“, managed in the CCIS.:
I don’t accept.
• I consent, in the event that the contract is concluded, to the fact that the data transferred to the CCIS in relation to the conclusion of the contract be made available from the CCIS to other reference data providers. (I am aware that my declaration to this effect relates to all my
previous contracts constituting the subject of data provision, and I am also aware that I am entitled to change my declaration to this effect at any time.):
I don’t accept.
• I ask the Bank that if the contract is concluded, the data that is forwarded to the CCIS in relation to the conclusion of the contract be managed by the CCIS for an additional five years following the end of our contractual legal relationship.:
I don’t accept.
Date: (place), day month year
* The CCIS Operator in contact with the Bank is, at present, Bankközi Informatika Szolgáltató Zrt., head office: 1205 Budapest, Mártonffy u. 25-27/. www.bisz.hu
**The amount of the monthly minimum wage as at any time is determined in the legal rules in force as at any time
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Customer’s signature
1. The Central Credit Information System and its purpose
The Central Credit Information System (hereinafter: CCIS) is a closed system database. The purpose of submitting data to and requesting
data from the CCIS (data forwarding) is to assure a sounder assessment of creditworthiness, to meet the conditions of responsible lending,
and to reduce lending risk in the interests of the security of debtors and reference data providers.
2. Cases of data provision to the CCIS, data that is to be provided by data providers in every case on an obligatory basis, as well
as data that is to be provided upon the occurrence of specifically defined cases, and the duration of data storage
2.1. Only the data specified in the CCIS Act may be managed in the CCIS (hereinafter: reference data). The reference data provider hands
over to the financial enterprise* that operates the CCIS (hereinafter: CCIS Operator) the reference data of the natural person who
a) enters into a contract with the reference data provider
• for the provision of credit or a cash loan,
• financial leasing services, or
• for the issuance of electronic money or a cash-substitute payment instrument (e.g. paper-based traveller’s cheques, bills of exchange),
and the provision of the service
related thereto which does not qualify as a payment service,
• for the provision of surety or a bank guarantee, or some other banker’s commitment, or
• who concludes a student loan contract as defined in a separate statutory regulation, or
• a contract for the provision of an investment loan to an investor, or
• for securities lending/borrowing (hereinafter: “positive debtor list”), within two workings days following contract conclusion. Prior to the
handover to the CCIS of the reference data related to the “positive debtor list”, the natural-person customer is entitled to issue a statement
as to whether he/she consents to having his/her data forwarded from the CCIS to other reference data providers. This consent may be refused
by the natural-person customer at any time during the period of recordkeeping of the data in the CCIS. If the natural-person customer does
not consent to the forwarding from the CCIS of his/her data, the refusal to give consent and the data related to the refusal [the date (date and
place) of the declaration, the identification data of the reference data provider, the customer’s identification data and a comment indicating
that consent was denied] will be recorded in the CCIS. The natural person customer’s written declaration shall apply to all the natural-person
customer’s contracts constituting the object of data provision. If the customer changes the substance of his/her declaration later on, and
withdraws or refuses his/her written consent, then in all cases the natural person customer’s most recently made written declaration shall
apply in respect of all his/her contracts constituting the object of data provision. Furthermore, we would like to inform you that a registered
natural-person customer may request in writing from the financial enterprise operating the CCIS, at the time of contract conclusion or during
the term of the contract – via the reference data provider – that the financial enterprise operating the CCIS manage his/her data related to
the “positive debtor list” for no more than five years following the termination of the contractual legal relationship. The consent for the
management of data after termination of the legal relationship may be withdrawn at any time in writing via the reference data provider prior
to termination of the legal relationship, and after that directly via the financial enterprise operating the CCIS.
b) a person who fails to comply with his/her payment obligations under one or more of the contracts listed in section a) in such manner
that the amount of overdue and unpaid debt exceeds the statutory monthly minimum wage** effective as at the time of the delay and such
overdue debt in excess of the minimum wage has been outstanding continuously for more than ninety days;
c) the person that provides false data upon requesting the conclusion of the contract related to the services stated in a) and there is
documentary evidence thereto and for the use of false or forged documents the final judicial decision establishes the crime stated in
Sections 342-343., 345-346. of Act C of 2012 on the Criminal code (forgery of public document, forgery of private document, misuse of
document).
d) a person who, due to the use of a cash-substitute payment instrument, is found by the court, in a legally binding ruling, to have
committed a crime specified in Article 393 of the Civil Code (abuse of a cash-substitute payment instrument) (sections b)–d) hereinafter
together: “negative debtor list”).
2.2. In the course of the handover specified in section 2.1, the Bank hands over to the CIS Operator the identification data of the natural
person [name, name at birth, date and place of birth, mother’s maiden name, number of personal identification document (passport) or the
number of a certificate that is, in accordance with Act LXVI of 1992 on the Registration of the Personal Data and Address of Citizens, suitable
for the verification of identity, address, correspondence address, email address], and a) in the case of section 2.1 a), the contractual data of
the contract specified therein [contract type and identification (number), the date of contract conclusion, expiry, termination, classification
of the customer (debtor, co-debtor), the contract amount and currency, the method and frequency of repayment, the installment amount
and currency of the contract amount], and furthermore, in the course of the data provision specified in section 2.1 b), the date on which the
conditions specified in section 2.1 b) are met, the amount of overdue and unpaid debt at the time that the conditions specified in section 2.1
b) are met, the manner and date of the termination of the overdue and unpaid debt, the assignment of the claim to another reference data
provider, reference to litigation, the occurrence and time of any prepayment, the amount of the prepayment, and the amount and currency
of the remaining principal debt,
b) in the case of section 2.1. c), the data pertaining to the initiation of the contract specified in section 2.1. a), [the date and reason for
the rejection of the application, documentary evidence, number of legally binding court resolution, name of acting court, content of the
operative section of the resolution],
c) in the case of subsection 2.1 d), the data pertaining to the use of the cash-substitute payment instrument [the type and identification
(number) of the cash-substitute payment instrument, the date of blocking, the date, number and amount of any transactions performed
with the blocked cash-substitute payment instrument, the number of unauthorized uses, the amount of the damage caused, the date on
which the court ruling became legally binding, reference to litigation],
d) the reference-data provider shall, by the fifth working day following the month concerned, specify to the CCIS Operator the amount and
currency of the outstanding capital debt, the amount and currency of the repayment instalment of the contractual amount, and further,
if the registered natural person performs prepayment during the term of the contract, it shall provide to the CCIS Operator, within five
working days following the prepayment, the data related to the prepayment [fact and date of the prepayment, the prepaid amount, and
the amount and currency of the outstanding principal debt].
2.3. The reference data handed over in accordance with section 2.2 is deleted by the CCIS Operator immediately after the termination of
the contractual relationship in the case specified in section 2.1, or if the consent specified in section 2.1 a) has been given, manages it
for five years after termination of the contractual relationship, and in the case specified in section 2.1 b) for a year after the repayment
of the debt, or for five years if the debt has not been repaid, and in the cases specified in sub-sections 2.1 c)–d) also for five years, after
the expiry of which period it finally and irreversibly deletes the reference data. In the cases specified in section 2.1. b)–d), with respect to
calculating the period, the starting date shall be:
a) in the case specified in section 2.1 b), the date of the elimination of the past-due debt, and if the debt has not been eliminated, the end
of the fifth year following the date of data provision,
b) the date of data provision in the cases specified in section 2.1. c)–d).
2.4. In a departure from the provisions of section 2.3, the CCIS Operator shall immediately and irreversibly delete the reference data if the
reference data provider has ceased to exist without a legal successor and the claim under the contract pertaining to the data provision was
not transferred to another reference data provider, or if the reference data provider transferred the claim under the contract pertaining to
data provision to an entity that is not a reference data provider. Furthermore, the CCIS Operator shall immediately and irreversibly delete
the reference data if it was entered into the CCIS unlawfully.
3. Data request from the CCIS
3.1. Based on the data provision specified in section 2, the CCIS Operator registers the data in the CCIS, following which the data becomes
retrievable and available for provision to other reference data providers on the basis of a data request submitted by them; in the case
specified in section 2.1 this only applies if the Customer has given his/her written consent thereto. The CCIS Operator may only accept the
reference data provided by the Bank and by other reference data providers, and may only make the reference data managed by it available
to the reference data providers based on the data request submitted by them. In addition to the reference data pertaining to the registered
person indicated in the data request, no other data may be provided from the CCIS to the reference data provider. The data request may
only be used for the purpose of making decisions that serve as the basis for concluding such contracts as are specified in section 2.1 a), or
for complying with the requirement of responsible lending or providing information, as specified in section 3.2, to the person concerned.
3.2. Anyone may request information from any reference data provider (including the Bank) about their data contained in the CCIS and
about the identity of the reference data provider that made the data available. The Bank forwards to the CCIS Operator, within two working
days, the request for information submitted by you; the CCIS Operator sends the requested data in a sealed manner to the Bank within three
days, and after receipt the Bank forthwith, but no later than within two working days, forwards the data to you, again, in a sealed manner,
by registered mail. The information is free of charge for the person requesting it and no reimbursement or other fee may be charged for it.
4. Legal remedies
4.1. If you believe that the Bank has handed over your data to the CCIS Operator unlawfully and/or the management of such data in the CCIS
is unlawful, the following legal remedies are available to you:
4.2. You may submit an objection to the Bank or the CCIS Operator requesting the correction or the deletion of the reference data. The
Bank and/or the CCIS Operator will review the objection within five working days of the receipt thereof, and shall notify you of the result
of the review, in writing by means of registered mail, forthwith but no later than within two working days after the review is completed.
If the Bank accepts the objection, it shall hand over forthwith, the reference data to be corrected or deleted to the CCIS Operator while
simultaneously notifying you, and the CCIS Operator shall make the required change to the records forthwith.
4.3. You may file a claim against the Bank and the CCIS Operator at the competent local court for unlawful provision and management
of reference data, or for the purpose of having the reference data corrected or deleted, if you disagree with the result of the review of
the objection (in this case, within 30 days of receipt of the notice regarding the review of the objection), and/or if the Bank or the CCIS
Operator fails to comply with its obligation to provide information as specified in section 3.2 (in this case within 30 days after the expiry
of the deadline stipulated with respect to the obligation to provide information.)
4.4. The CCIS Operator shall keep on record the fact that legal action has been launched, together with the disputed reference data, until
the matter is resolved in a legally binding manner. I the undersigned confirm that Citibank Europe plc. Hungarian Branch Office, in its
capacity as reference data provider, has met its obligation to provide information prior to the initiation of the conclusion of a contract,
or prior to the actual conclusion of the contract, in relation to the Central Credit Information System, as prescribed in the CCIS Act, by
handing over this written Notice and the publication entitled “Information from the Hungarian Financial Supervisory Authority for private
individuals regarding the Central Credit Information System”, and – if the customer is present in person – by providing the relevant oral
explanations, and that I acknowledge the information thus communicated to me
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Further declarations relating to credit card applications
I hereby accept that if, based on the decision of the Bank’s Credit Assessment Department, I am not eligible for the Bank credit card product requested simultaneously with the completion of the present declaration, the Bank or its Bank Agent
may contact me with further Citibank credit card product offers. Yes
No
I hereby declare that I submit my present credit card application to the Bank as an application for a second or further credit card. Number of my existing Citibank credit card:
If, based on the decision of Citibank’s Credit Assessment Department, no further credit facility may be approved for me in conjunction with the present credit card application, I hereby accept that the present card application shall constitute an
amendment to my existing Citibank credit card contract, that is, simultaneously with the issuance of the new card requested as part of the present application, my existing card shall be blocked. In this case, the provisions set forth in Clauses
II/30 to 34 of the GTC and the consent herein below shall govern. Yes
No
Declaration under the legislation concerning the prevention of money laundering
Declaration under Section 8 of Act CXXXVI of 2007 on the Prevention and Combating of Money Laundering and Terrorist Financing. I hereby declare that, for the purposes of the financial product/service stated in the present contract, I
proceed as a natural person
on my own behalf
on behalf of the following person (beneficial owner).
Details of beneficial owner (to be completed only in case of second alternative):
First name(s) and surname: Name at birth if different:
Address *: Nationality:
I hereby accept that I am entitled to issue a declaration in deviation from the above in respect of individual transaction orders. Being aware of my liability under criminal law, I hereby declare that the above details are true and correct. I hereby accept that I am obliged to inform the Bank of
any changes in the details supplied as part of the identification procedure within five business days of such changes coming to my attention.
*If you reside abroad, you have to complete the declaration of customer residing abroad.
Declaration of customer residing abroad.
I declare that pursuant to the following I am not a senior public figure. (Please mark with an X.) I declare that pursuant to the following I am a senior public figure (Please enter the code of the appropriate category below):
The undersigned, hereby consent to the disclosure by Citibank Europe plc. Hungarian Branch Office of the data stated in the present Application Form to the associated businesses determined in the Accounting Act, in harmony with the provisions
of the Act on the Prevention of Money Laundering, for the purposes of customer vetting serving to prevent money laundering.
1a) Head of state, heads of government, ministers and deputy or assistant ministers
1b) Member of Parliament
1c) Member of the Supreme Court, of Constitutional Court or of other high level judicial bodies whose decisions are no subject to further
appeal
1d) the head of the court of auditors, member of the courts of auditors, member of the ultimate decision making organ of the central bank
1e) ambassador, agent in charge and professional senior officers of the armed forces of general ranks and function
1f) member of the management, the board or the supervisory body in undertaking with majority holding by the state
1g) executive officers of international organizations
1h) Mayor of the capital city
1i) Trade union leaders
1j) Head of national civil organization
2) close relative of the person mentioned in Section 1), that is, a close relative as defined in Section 685, paragraph b) of the Civil Code
(spouse, direct-line relative, adopted, step or foster child, adoptive, step or foster parent, brother/sister, cohabitee, spouse of direct-line
relative, engaged to person mentioned in Section 1), direct-line relative, brother/sister of spouse, spouse of brother/sister)
3a) any natural person who is the actual owner of a legal entity or unincorporated association jointly with a person mentioned in Section 1)
or is engaged in a close business relationship with a person mentioned in Section 1)
3b) any natural person who is the single-entity owner of a legal entity or unincorporated organization which was established for the benefit
of a person mentioned in Section 1)
Customer’s signature
Declaration concerning salary transfers
Employer’s name:
Address: Postcode: City:
Street: No.: Floor, door No.:
In the case of a credit card contract, with reference to Section 158 (1) of Act I of 2012 on the Labor Code I, the undersigned
Name:
Date of birth:
Mother’s name:
as employee, hereby authorize and request my employer to transfer, maximum 33% of my salary to my account number
- - monthly,
and to make the said transfers up to the amount of HUF
My Declaration on salary transfer shall enter into force when it is forwarded to the Employer.
Date: (place), day month year
Employee’s signature
CitiPhone Banking: +36 1 288 88 88
Citibank Europe plc. Hungarian Branch Office (registered offices: H-1051 Budapest, Szabadság tér 7.;
registration court and court number: Municipal Court of Budapest, acting as Court of Registration 01-17-000560);
acting in the name and on behalf of Citibank Europe plc. (registered office: 1 North Wall Quay, Dublin 1,
registration court and court number: Companies Registration Office, no. 132781) an entity registered in Ireland).
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5/5. page
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To be completed by the Bank
To be completed by the Bank
