Request for a Citi credit card. ✓ ❏ YES, Subject to acceptance of my request, in order to increase my purchasing power in a renewable way, depending on my installments. Please send me a personalised proposition for a Citi credit card without any commitment on my behalf. Choose the credit card you want to apply for (tick the box) : ❏ Citi Visa ❏ Citi Visa Student ❏ Citi Neckermann Visa ❏ Citi MasterCard ❏ Citi MasterCard Student ❏ Yes, I am already a Neckermann customer. My customer number is : ❏ Citi Travel Pass World MasterCard ❏ No I don't have a neckermann number yet, can you please create one for me. ❏ Citi Visa Gold i choose a credit opening* of maximum : ❏ Citi Proximus Visa ❏ Business ❏ Residential ❏ 2.000 ❏ 3.000 ❏ 5.000 * for a credit opening of more than 3.000 , please find here enclosed a proof of my last income. i would like to receive my mailing in : ❏ French ❏ Dutch ▼ PERSONAL DATA CDS/APPS OPS/1009-E ❏ Mr ❏ Ms ❏ Mrs Surname First name Street N° Box Postal code City/Town Tel. / Gsm / Editor in charge: M. De Bolle - Credit Provider: Citibank Belgium SA/NV, Bd General Jacques 263g, B-1050 Brussels - VAT BE 0401.517.147 RPM/RPR Brussels - IBAN : BE77 9545 4622 6142 - BIC : CTBKBEBX. I live at this address since : year ❏ Owner ❏ Tenant ❏ Parental home E-mail address Mother's maiden name National register number / / ID Card number / / Date/birth Place of birth Nationality day month year Civil status : ❏ Single ❏ Married ❏ Separated ❏ Divorced ❏ Widowed Number of dependents Name of my bank Since year ▼ PROFESSiONAL DATA I am : ❏ Worker ❏ Employee ❏ Retired ❏ Unemployed ❏ Housewife ❏ Allowance ❏ Student ❏ Independent ❏ Liberal profession Profession Employer Employer activity Street N° Box Postal code City/Town Tel. / Since / VAT-nbr if applicable : BE - month year ▼ FiNANCiAL DATA (mandatory) Revenues : Net monthly salary : Charges : Monthly rent /month – of myself /month Monthly mortgage payment /month – of my partner /month Total outstanding credit lines Other monthly income /month Total other outstanding loans /month Child benefits /month Other charges /month Alimony and child support /month Alimony and child support /month The credit card will be sent to your home address. Return (with 2-sided copy of your iD card or passport) to : Citibank Cards, Bd General Jacques 263g, 1050 Brussels, or fax it to 0800/200.97. I certify that all information provided in this document is complete I hereby declare not being, and not being related to, a person who is or has been a Politically Exposed and accurate. By completing this document accurately, my application will be treated quickly and confidentially. Person(*). If this is not the case, I am ticking this box ❏ (*) If you would like to know the complete definition of a "Politically Exposed Person", please go to our website www.citibank.be/PEP. Date : Signature mandatory : i wish to receive personalized offers ❏ by SMS ❏ by e-mail I do not wish to receive personalized offers ❏ by post ❏ by telephone I authorize the Bank to process my personal data ("data") in accordance with the principles defined in this clause. I acknowledge that the Bank may ✘ also transfer my data to countries outside of the European Union, in connection with the purposes described in this clause, based on an agreement containing EU standard contractual clauses. The Bank will process my data in accordance with the Belgian Data Protection Act 1992. The Bank may process my data in connection with providing and managing its products and services, assessing my credit worthiness, offering me products and services, participating in the prevention and detection of fraud and related crimes, producing statistics, management information and executing tests, complying with anti-money laundering, terrorism and related legislation and complying with other legal and regulatory obligations. Access to my data is allowed only to those people who need this for the execution of their job. The Bank may share my data with other Citi affiliates, or with its service providers. Citibank requires such affiliates and service providers to keep the data confidential. The Bank notifies the processing of personal data to the Privacy Commission. I am entitled to request an overview of the data held on the Bank's databases, and to have any incorrect information corrected, by sending my request in writing, together with a copy of both sides of my identity card, to Citibank Belgium NV/SA, Data Controller, Bld. General Jacques 263g, B-1050 Brussels, Belgium. I may request that the Bank ceases to use my data for direct marketing purposes at any time, by simply asking a branch or agency to record your request, or by letter to the Marketing Department of the Bank.