Fillable Printable Security Bank Credit Card Application Form
Fillable Printable Security Bank Credit Card Application Form
Security Bank Credit Card Application Form
CITIBANK BERHAD (297089-M)
CITIBANK SUPPLEMENTARY CREDIT CARD APPLICATION FORM
JUNE 2013
Please attach a photocopy of your supplementary applicant’s NRIC and
submit this form to:
CITIBANK BERHAD (297089-M)
Cards Telemarketing Department,
Level 14, Menara Citibank,
165, Jalan Ampang, 50450 Kuala Lumpur
Fax: 03-2383 9981
Tel No: 1300-13-5555
Terms and Conditions
The use of Citibank Credit Cards (“Card”) is governed by the Citibank Card Terms and
Conditions (which will be provided to me/us upon successful application) and the relevant
terms and conditions for specific Card-type, whichever is applicable, and is binding on the
Principal Cardmember(s) and the Supplementary Cardmember(s). (2) The Principal
Cardmember shall be responsible for all liabilities and obligations of the Principal
Cardmember as well as the Supplementary Cardmember(s). The Principal Cardmember is
jointly and severally liable to us for all amounts and charges due and owing to us from the
use by the Supplementary Cardmember(s) of his/her own Supplementary Card(s). (3) Any
Card(s) issued to me/us, including Supplementary Card(s) must not be used by me/us for
any unlawful activity or purpose (including without limitation online gambling), whether in
whole or part. (4) For principal card applications: I understand that if I am submitting this
application for more than one or multiple Citibank credit cards, I may be participating in
more than one Citibank credit card promotion in which gifts are given for successfully
approved applications. In such event, I hereby CONFIRM that I am the only one entitled to
receive the gift from only ONE of such promotions, regardless of the number of Citibank
credit cards that are successfully approved. For this purpose, and subject to Citibank’s
approval of my applications, my preference of the gift is as indicated on page 1.
By signing below, I confirm that (1) I have read and agree to abide by the provisions
contained in General Declaration for Citibank Credit Card and (2) My minimum income is
RM24,000 per annum or more. (3) For CitiBusiness Card application, my business sales
turnover is RM120,000 per annum or more (N/A if Business Platinum card applicant is
salaried). (4) My signature below constitutes a request for Citibank VISA credit card if I
already have a Citibank MasterCard and vice versa, if applicable. (5) My signature
constitutes a request for Gold/Classic Card if I do not qualify for Platinum/Gold Card. (6) The
Principal and Supplementary Cardmember(s) will be jointly and severally liable to the Bank
for all amounts and charges due and owing however arising from the use by the
Supplementary Cardmember(s) of his own Supplementary Card(s)”. (7) The Bank may allow
the Principal Cardmember(s) to exceed the credit limit/total credit limit and/or the
Supplementary Cardmember(s) to exceed the Supplementary Card(s) limit (if a separate
credit limit is assigned) at the Bank’s sole discretion. (8) The Principal Cardmember(s) and
the Supplementary Cardmember(s) will be bound by the Citibank Card Terms and
Conditions. (9) I have received, read and understood the contents of the Citibank Credit Card
Product Disclosure Sheet.
Citibank’s Privacy Notice
Keeping personal data of individuals secure is a top priority for all of us at Citibank. Please
visit us at www.citibank.com.my/privacyEng to view our Notice and Choice Principle
Statement where we seek to outline how we intend to deliver all the rights and protections
that you are entitled to in respect of your personal data.
Date of application (Mandatory) :
Supplementary card
Applicant :
Applicant’s signature :
yyyydd mm
FOR BANK’S USE
Agent Code Card Source Code
Form Filled Up By
Staff Applicant
(✍ Sign in black ink only)
Jika anda ingin memasuki kontrak dalam Bahasa Malaysia, sila minta borang tersebut daripada kami. Jika anda menandatangani Borang Pemohonan ini dalam Bahasa Inggeris, anda dianggap telah
memilih dan memahami Bahasa Inggeris sebagai bahasa utama untuk kontrak ini.
1 PRINCIPAL CARDMEMBER
Citibank Credit Card Number :
Name of Principal Card :
Full name as in NRIC or passport (underline surname) : Mr Mrs Ms
Full name as in NRIC or passport (underline surname) :
Name to appear on card (max. 19 letters) :
Date of birth : Nationality :
New NRIC no. or passport no. : Old NRIC no. :
Relationship to principal cardmember :
Residential Address. The supplementary card will be sent to the principal
cardmember’s preferred address :
Home tel no. :
Handphone no. :
State : Postcode :
YES, I wish to assign monthly spend limit of
Reminder: The total combined spend cannot exceed the principal cardmember
current approved credit line. CitiBusiness VISA Requirement — For employees
only: minimum income of RM24,000 per annum and minimum age of 21.
RM
--
Mr Mrs Ms
CONSENT FOR CITI PRESTIGE GLOBAL CONCIERGE3
By signing below, I hereby (1) authorise Citibank Berhad (“the Bank”) to
disclose my personal data, such as my name, address(es), contact numbers,
e-mail address(es) and information pertaining to this application to TEN
Lifestyle Management Ltd (“TEN”) for purposes of providing Citi Prestige
Global Concierge services to me, (2) understand that any personal data
provided by the Bank to TEN shall also be subject to the TEN’s privacy policy
of which details can be located at http://www.tenlifestyle.com/privacy and to
the full extent permitted by law, the Bank shall not be liable for any
unauthorised disclosure of personal data or breach of confidentiality, and (3)
agree to indemnify and hold the Bank harmless against any liability to the full
extent permitted by law arising from the disclosure of my personal data.
Date of application (Mandatory) :
yyyydd mm
CitiBusiness VISA: For employees only with minimum income of RM24,000
per annum and minimum age of 21.
2 SUPPLEMENTARY CARD
yyyydd mm
Residential address :
Applicant’s signature :
(✍ Sign in black ink only)
Citi Prestige MasterCard World Elite
Citi PremierMiles AMEX
Citi PremierMiles VISA Signature
Platinum MasterCard
Platinum VISA
Cash Back Platinum VISA
Choice VISA
Clear MasterCard
Clear VISA
Rewards Platinum VISA
Rewards Platinum MasterCard
Cash Back Platinum MasterCard
Business Platinum VISA
CitiBusiness Gold VISA
AirAsia Gold MasterCard
AirAsia Platinum VISA
Shell Gold VISA
AirAsia MasterCard
Giant VISA
AirAsia Gold VISA
Choice MasterCard
6
GENERAL DECLARATION FOR CITIBANK CREDIT CARD
Citigroup has outsourced the performance of its/their operational functions (whether within
or outside Malaysia), in connection with this application or any products, service or
accommodation I/we have or may have with the Bank, for confidential use, processing this
application, data processing, credit evaluation, meeting legal and regulatory requirements,
for provision of goods or services, marketing and promoting any products, service and/or
accommodation to me/us, provision of services such as protection plans or insurance
policies where applicable (including assessing, processing and investigating any risks or
claims), fulfillment and delivery of gifts to me/us in connection with this application, my/our
Card(s), the Card Terms and Conditions and all other purposes incidental and associated
with any of the above.
(4) I/We declare that my/our spouse(s), children or parents (if any) is/are not employee(s) or
director(s) of the Bank in compliance with the Banking and Financial Institutions Act, 1989
(“BAFIA”). I/We also declare and understand that my/our application is subject to
non-applicability of the restrictions found in Section 62 of BAFIA and provided that I/we
am/are not in breach of or in contravention of the laws of Malaysia, failing which, you are
entitled to terminate my/our Card(s).
(5) I/We fully understand that the approval of my/our application is at your discretion as you
may deem fit and you may at any time terminate my/our Card(s) with notice.
(6) I/We will keep you fully indemnified against any claims, actions, proceedings, losses,
damages, costs and charges as a result of using and/or in connection with the Information,
Card(s), Citibank Card Terms and Conditions and all relevant agreements, covenants and
undertakings by me/us.
(7) I/We expressly consent to the mailing of my/our Card(s), Debit & ATM Card, the Citibank
Card Terms and Conditions, the relevant Terms and Conditions for specific Card-type (if
applicable), to my/our address(es) provided here if my/our application is successfully
approved.
The general information provided by Citibank in this Application Form is valid as at 17 June 2013.
I/We hereby declare, acknowledge, agree and confirm as follows:
(1) I/We warrant that all information furnished here is true, accurate and not misleading.
(2) I/We authorise Citibank Berhad (“the Bank”), at any time and from time to time to
process including but not limited to access, obtain, verify and/or use, any data or
information from any source (including credit reference agencies, credit reporting agencies,
Bank Negara Malaysia (“BNM”), the credit bureau and/or the Central Credit Reference
Information System (“CCRIS”) and such relevant authorities) for purposes of evaluating
my/our credit standing in connection to me/us, this application and any facility, service or
accommodation I/we have or may have (whether or not with the Bank) as the Bank’s
discretion deems fit. I/We understand that this application, the opening, operation and
conduct of my/our Card Account, Citibank Ready Credit Account and any future facility,
service or accommodation applied by me/us or granted by you (whether in my sole name or
jointly with another or others, including the Supplementary Cardmember(s), presently or
subsequently opened) may be reported to the Dishonoured Cheques Information System
(“DCHEQS”) maintained by BNM, CCRIS and such relevant authorities (as the case may be)
as the Bank deem fit.
(3) I/We authorise the Bank to disclose, store, utilise and/or transfer my/our personal data such
as my/our name, address(es), contact numbers, information obtained from credit reference
agencies, credit reporting agencies, BNM, the credit bureau, CCRIS and such relevant
authorities pertaining to this application and/or any facility, service or accommodation applied
by me/us or granted by the Bank (whether in my sole name or jointly with another or others,
including the Supplementary Cardmember(s), presently or subsequently opened ) and whether
within or outside Malaysia (“Information”) to/with Citibank Berhad, Citibank N.A., Citigroup Inc.
or any of your/their officers, affiliates or subsidiaries (collectively “Citigroup”), merchants,
VISA International Services Association, MasterCard International Incorporated, American
Express, or any other card associations, any vendors and/or third party service providers
engaged by the Bank and/or Citigroup, including any person to whom the Bank and/or
JUNE 2013
PUBLIC FIGURE DECLARATION (FOR PRINCIPAL CARD)
(e.g. ministerial/diplomatic positions)
4
PUBLIC FIGURE DECLARATION (FOR SUPPLEMENTARY CARD)
(e.g. ministerial/diplomatic positions)
5
Senior public office :
Position held :
Position held from
Yes, I/my immediate family members
No, I / immediate family members do not hold, have never held, are not actively seeking and
are not being considered for senior public office.
to
YYDD MM YYDD MM
Currently hold / Seeking
Senior public office (e.g. Heads of States or of government, senior politicians, senior
government, judicial or military officials, senior executives of state-owned corporations and
important political party officials).
Have Held
Senior public office :
Position held :
Position held from
Yes, I/my immediate family members
No, I / immediate family members do not hold, have never held, are not actively seeking and
are not being considered for senior public office.
to
YYDD MM YYDD MM
Currently hold / Seeking
Senior public office (e.g. Heads of States or of government, senior politicians, senior
government, judicial or military officials, senior executives of state-owned corporations and
important political party officials).
Have Held
