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					Corporate Card System
Cardmember Application Club Rewards ®/Club Cash ® Enrollment Individual Billing

Citicorp Diners Club Inc. P.O. Box 5064 Denver, CO 80217-5064
For Organization’s Travel Manager Use: 16-digit Summary Account #

*Application cannot be processed without this required information.
DINERS CLUB CORPORATE CARD ENROLLMENT (EMPLOYEE INFORMATION)
*FIRST NAME MIDDLE *LAST ORGANIZATION NAME HOME STREET ADDRESS – 2nd LINE (no P.O. Box) BILLING ADDRESS – 2nd LINE *HOME TELEPHONE *CITY CITY *SOCIAL SECURITY NUMBER *STATE *ZIP ZIP

*HOME STREET ADDRESS (no P.O. Box) BILLING ADDRESS (if different than above) *BUSINESS TELEPHONE

xxxx
STATE *DATE OF BIRTH (dd/mm/yyyy)

(

)

(
*E-MAIL ADDRESS

)
TO DESIGNATE ANOTHER PERSON TO MANAGE YOUR ACCOUNT, INDICATE BELOW Name: Relationship:

*PASSWORD (for security purposes)

CLUB REWARDS ENROLLMENT (OPTIONAL)
Yes! I want to earn Club Rewards points whenever I charge to my Diners Club Corporate Card. I understand that the annual Club Rewards fee, currently $75, includes a no-fee Diners Club Personal Card for my personal use, if I qualify. This will allow me to maximize my Club Rewards points through personal charges in addition to the points I will earn with my Diners Club Corporate Card. Billing statements for the personal card will be sent to the home address listed above. Enroll me in Club Rewards and send me a no-fee Personal Diners Club Charge Card upon approval. Enroll me in Club Rewards only.

CLUB CASH ENROLLMENT (OPTIONAL)
By checking this box, ask to be enrolled in the “Club Cash” cash advance program. I understand that I may only enroll in the Club Cash Program with the approval of my Organization. Diners Club will choose a PIN and mail it to you. Upon receipt of your assigned PIN, if you would prefer to replace it with a PIN of your choice, call Diners Club Customer Service at 1-800-2-DINERS.

TERMS AND CONDITIONS
I (the Applicant above) request that Citibank U.S.A., N.A. (“Diners Club”) consider my application for a Diners Club Corporate Card. By signing below or transmitting this form by e-mail, I certify that I have read the application and agree to its terms. I agree to be bound by the terms of the Diners Club Cardmember Account Agreement (“Agreement”) that will be sent with the card. The Agreement will bind me unless I cancel my Account within 30 days after receiving my card and I have not used or authorized use of my Account. Diners Club may change the Agreement at any time in accordance with its terms. I authorize Diners Club to gather information about me from my Organization, credit bureaus and others to verify my identity and eligibility for the Account. If I ask, Diners Club will tell me whether it requested a credit bureau report and the names and addresses of any applicable credit bureau. I authorize Diners Club to transfer information about my application or Account to Diners Club International, its franchises and affiliates, my Organization, and its affiliates. I will use my Diners Club Corporate Card only for my Organization’s business purposes. To receive a Diners Club Corporate Card, I must meet Diners Club’s qualification criteria. Diners Club reserves the right to impose charge limits and will inform me in a separate letter if a charge limit applies. Federal law requires Diners Club to obtain, verify, and record information that identifies each person who opens an account, in order to help the government fight the funding of terrorism and money laundering activities. To process the application, Diners Club must have my name, street address, date of birth and other identifying information, and Diners Club may ask for identifying documents from me as well. If I have requested a Diners Club Card, I have read and agreed to the Personal Card Terms and Conditions, rates, fees and other costs on page 2 of this application.
APPLICANT SIGNATURE (required for form is printed) DATE

X
ORGANIZATION INFORMATION AND AUTHORIZATION (TO BE COMPLETED BY THE TRAVEL MANAGER)
NAME OF ORGANIZATION REQUESTING CARD ISSUANCE ADDRESS OF ORGANIZATION CITY STATE ZIP

Cardmembers will be assigned a daily and weekly cash advance limit in accordance with Diners Club Policy and the Organization’s agreement with Diners Club. If different limits are desired for this Applicant, please call Client Services at 1-800-964-9444. Diners Club must approve exception limits.

FIELD 1

FIELD 2

FIELD 3

FIELD 4

FIELD 5

FIELD 6

AUTHORIZED SIGNATURES AND TITLES (REQUIRED IF FORM IS PRINTED)
AUTHORIZED SIGNATURE AND TITLE AUTHORIZED SIGNATURE AND TITLE

X
MKT 6159 IBS-C (2/05) UMM JAT002B54

X

FOR DINERS CLUB USE ONLY DATE PROCESSED BY

Corporate Card System
Cardmember Application Club Rewards ®/Club Cash ® Enrollment Individual Billing
PERSONAL CARD TERMS AND CONDITIONS
Club Rewards Program Miles will be awarded as Club Rewards points for each month in which you make a qualified charge (excludes annual fee, cash advances and insurance charges) to your Personal Diners Club Charge Card account. Your Diners Club Charge Card account must be open and current to redeem Club Rewards points. Points may be subject to forfeiture for delinquency. Redemptions for frequent flyer miles must be made in 1,000 mile increments. A fee may apply when Club Rewards points are redeemed. Only the Primary Cardmember is eligible to receive Club Rewards points, but points accrue for all qualified spending including any from additional Cards on the account. See Club Rewards Terms & Conditions at www.clubrewards.dinersclubus.com for complete details. Diners Club Charge Card Annual Fee Payment Terms Club Plus Account APR Variable rate information Method of computing the balances for Club Plus Account $95 for Primary Cardmember* $35 for each Additional Cardmember All charges made on this charge Card are due and payable when you receive your periodic statement. Prime + 8.0% Your Club Plus Account APR may vary each billing period. The Club Plus Account rate equals the U.S. Prime Rate† plus 5.25%. Average daily balance

Minimum finance charge on Club 50 cents Plus Account Transaction fee for purchases made in a foreign currency 3% of the amount of each foreign currency purchase after its conversion into U.S. dollars.

* The Annual Fee for the primary card is waived as long as you remain a Corporate Club Rewards Cardmember in good standing. Otherwise, the Annual Fee of $95 for the primary card will
apply. For each Additional Card, the standard Annual Fee of $35 will be assessed. The Annual Fees are non-refundable. † For billing periods beginning in May through October, we will use the U.S. Prime Rate published in The Wall Street Journal on the first business day of the immediately preceding March. For billing periods beginning in November through April, we will use the U.S. Prime Rate published in The Wall Street Journal on the first business day of the immediately preceding September.

Transaction fee for Club Cash® Advances: The greater of $4.00 or 4% of each Club Cash Advance. Late Fee and Delinquency Fee. We will impose a delinquency fee of $30 each time the oldest portion of a Total Due balance is included in a Past Due balance for the first time and the Past Due balance is more than $80.00. In addition, we will impose a late fee of 2.5% of the entire Past Due balance each time any portion of a Total Due balance is included in a Past Due balance and the Past Due balance is more than $80.00. This information is accurate as of February 11, 2005. This information may change after that date. To find out what may have changed write to us at Diners Club, PO Box 44180, Jacksonville, FL 32231-4180 By submitting this Application the Applicant authorizes Citibank USA, N.A., (“we or us”) the issuer of the Diners Club Charge Card, and its affiliates to investigate, verify and exchange information regarding their creditworthiness and to verify your identity. Each applicant must currently be at least 18 years of age and in good standing with all accounts with us or our affiliates in order to be approved for the Diners Club Charge Card. Consumer reports will be requested in connection with the processing of this Application and subsequently in connection with any update, renewal, or extension of credit. Upon request, each Applicant will be informed of the names and addresses of any consumer reporting agencies, which have provided such reports. You understand that your Diners Club Charge Card Account may not be issued to you if the form or application is not complete, accurate or verifiable. You understand that you must have a minimum verifiable gross household income of $25,000 per year. We apply your payments to low APR balances before higher APR balances. That means your savings will be reduced if you make transactions that are subject to higher APRs. Federal Law requires us to obtain, verify, and record information that identifies each person who opens an account, in order to help the government fight the funding of terrorism and money laundering activities. To process the application, we must have your name, street address, date of birth, and other identifying information, and we may ask for identifying documents from you as well. If you do not wish to receive direct mail or telemarketing offers, please write to the address below and include your name, address, and phone number. Citibank USA, N.A. c/o Citicorp Credit Services, Inc. P.O. Box 6020, Hagerstown, MD 21741-6020 Each Applicant agrees that use of any Card issued as a result of this Application will be governed by the Card Agreement provided at the time the Card is issued. Each Applicant also agrees that any disputes will be subject to binding arbitration, if either you or we elect arbitration (except for individual suits in small claims court). In arbitration, there is no judge and no jury, and there will be no class actions or other representative proceedings. Participating airlines, hotels and car rental companies are subject to change and may be discontinued without notice. Diners Club and Club Rewards ® are trademarks of Diners Club International, Ltd. Benefits are subject to certain terms and conditions. Specific benefits and rewards are subject to availability and may be changed or discontinued without notice. Citicorp Diners Club Inc. is a service provider for Citibank USA, N.A. the issuer of the Diners Club Charge Card. This offer is non-transferable, may not be combined with any other offer and is subject to change without notice. © 2005 Citicorp Diners Club Inc. All rights reserved MasterCard is a registered trademark of MasterCard International Incorporated. Worldwide MasterCard credit card acceptance applies only to Diners Club Cards issued in the United States and Canada.
MKT 6159 IBS-C (2/05) UMM JAT002B54


				
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