IMPORTANT: Before completing this application, please read the following carefully:
You may apply for Citibank Purchasing card(s) to be issued to your employees/officers whom you nominate as cardholders in the nomination form(s) (“proposed cardholders”) and be liable for all charges. Please complete this application form in full and a Citibank Purchasing card nomination form for each proposed cardholder. You must submit certified true copies of your audited financial statements for the last two years.
YOUR CHOICE OF CARD:
REGISTERED NAME
VISA
OR
MASTERCARD
BANK REFERENCE
BANKING RELATIONSHIP WITH CITIBANK (IF ANY)
COMPANY’S PARTICULARS
REGISTRATION NO.
DATE OF REGISTRATION
CITIBANK ACCOUNT NO(S).
*PLACE OF INCORPORATION
*PAID UP CAPITAL
NAME & CONTACT NO. OF CITIBANK RELATIONSHIP OFFICER
NATURE OF BUSINESS SET UP OTHER BANKER SINGAPORE-INCORPORATED COMPANY PUBLIC LISTED CORPORATION OTHERS (PLEASE SPECIFY) OTHER BANKER’S ACCOUNT NO. TYPE OF BUSINESS FOREIGN CORPORATION
AUTHORISED SIGNATORY OF COMPANY
BUSINESS TEL. NO. BUSINESS FAX NO. DECLARATION BY SIGNING BELOW, I APPLY TO BE A CORPORATE APPLICANT AND FOR CARD ACCOUNT(S) TO BE OPENED AND CARD(S) TO BE ISSUED TO EACH OF THE PROPOSED CARDHOLDERS FROM TIME TO TIME UNTIL THEIR CARD ACCOUNT IS TERMINATED. I AGREE TO BE LIABLE FOR ALL CHARGES AND OTHER LIABILITIES INCURRED OR OTHERWISE PAYABLE BY THE PROPOSED CARDHOLDERS AND I AGREE TO BE BOUND BY THE CITIBANK PURCHASING CARD AGREEMENT AND THE TERMS OF THE PROPOSAL LETTER PREVIOUSLY ACCEPTED BY YOU UPON ACCEPTANCE OF MY APPLICATION (WHICH MAY BE COMMUNICATED TO ME OR THE PROPOSED CARDHOLDER(S). I WARRANT THAT THE INFORMATION FURNISHED IN THIS APPLICATION FORM IN ANY DOCUMENTS OR ATTACHMENTS GIVEN TO YOU IN CONNECTION WITH THIS APPLICATION BY ME OR ANY OF THE PROPOSED CARDHOLDERS IS TRUE AND ACCURATE. I AUTHORISE ALL PERSONS/ENTITIES AS YOU MAY DEEM APPROPRIATE TO REQUEST FOR ANY INFORMATION ( CONFIDENTIAL OR OTHERWISE) RELATING TO ME IN ANY WAY, TO RELEASE THE SAME TO YOU WITHOUT REFERENCE TO ME. I CONSENT TO YOUR DISCLOSURE TO ANY THIRD PARTY AS YOU DEEM FIT AT YOUR ABSOLUTE DISCRETION ANY INFORMATION RELATING TO ME IN ANY WAY. I AUTHORISE YOU TO EMBOSS NAME(S) AS SET OUT ABOVE ON THE CARD(S). I CONFIRM THAT THE WARRANTIES AND AUTHORISATIONS ABOVE SHALL BE RELIED ON FOR THE PURPOSE OF ASSESSING MY APPLICATION AS WELL AS FOR THE CONTINUING OPERATION OF THE CARD ACCOUNT(S). NAME OF AUTHORISED SIGNATORY
REGISTERED ADDRESS
POSTAL CODE
MAILING ADDRESS IN SINGAPORE
POSITION/TITLE POSTAL CODE
SIGNATURE & BUSINESS STAMP NAME & DESIGNATION OF PERSON RESPONSIBLE FOR PAYMENT
DATE COMPANY’S NAME TO APPEAR ON CARD(S) (MAX 19 CHARACTERS) A D
FOR BANK USE
C BT BC GTR
PARENT COMPANY (IF APPLICABLE)
TOTAL CORP PURCHASING/CREDIT LIMIT COMM EXP MASTER CUSTOMER NUMBER CODE I ISSUED BY
NAME OF PARENT COMPANY & ADDRESS MASTER CARD NUMBER CORPORATE CUSTOMER NUMBER
PAYMENT INSTRUCTIONS STANDING INSTRUCTIONS INTERBANK GIRO
PLEASE SEND MASTER STATEMENT OF ACCOUNT TO DIVISION/DEPT/UNIT
Co. Reg. No: 200309485K
NOTE: (A) THIS APPLICATION FORM MUST BE SIGNED ON THE CORPORATE APPLICANT’S BEHALF BY ITS AUTHORISED REPRESENTATIVE. CITIBANK MAY REQUIRE THE CORPORATE APPLICANT TO FURNISH A CORPORATE RESOLUTION IN CITIBANK’S PRESCRIBED FORM CONFIRMING THIS. (B) CITIBANK HAS THE RIGHT TO REJECT ANY APPLICATION OF A CORPORATE APPLICANT AND/OR ANY NOMINATION OF A PROPOSED CARDHOLDER WITHOUT FURNISHING REASONS. CITIBANK PURCHASING CARDS WILL BE ISSUED TO SUCCESSFUL PROPOSED CARDHOLDERS. (C) PLEASE DO NOT INCLUDE PAYMENT WITH THIS APPLICATION. WE WILL BILL YOU AFTER APPROVAL.
EØ98VØØØ
AUTHORISED SIGNATORY OF COMPANY
I HEREBY NOMINATE MY EMPLOYEE/OFFICER NAMED BELOW AS A CITIBANK PURCHASING CARDHOLDER AND APPLY FOR CITIBANK PURCHASING CARD(S) TO BE ISSUED TO HIM/HER FROM TIME TO TIME UNTIL HIS/HER CARD ACCOUNT IS TERMINATED IN ACCORDANCE WITH THE CITIBANK PURCHASING CARD AGREEMENT. NAME OF AUTHORISED SIGNATORY (AS IN CORPORATE APPLICATION) DR
PARTICULARS OF PROPOSED CARDHOLDER
FULL NAME AS IN NRIC/PASSPORT (UNDERLINE SURNAME) MR MS
CARDHOLDER’S NAME TO APPEAR ON CARD (MAX 19 CHARACTERS)
DATE OF BIRTH POSITION/TITLE
SEX
NATIONALITY
NRIC/PASSPORT NO.
HOME ADDRESS
DIVISION/DEPT/UNIT
POSTAL CODE
COMPANY’S BILLING ADDRESS (MAILING ADDRESS) SIGNATURE OF AUTHORISED PERSONNEL(S) & COMPANY STAMP
POSTAL CODE
PAGER NO.
HANDPHONE NO.
HOME TEL NO. PURCHASING LIMIT SINGLE TRANSACTION LIMIT
OFFICE TEL NO.
FAX NO.
POSITION/JOB TITLE
DAILY LIMIT (OLA) DIVISION/DEPT/UNIT LEVEL MAX DAILY TRANSACTION COUNT 10 8 6 4 2 NO RESTRICTIONS NO RESTRICTIONS MAX DAILY S$ TRANSACTION LIMIT 10,000 NO. OF YEARS EMPLOYED BY CORPORATE APPLICANT B C D E F G 8,000 6,000 DECLARATION OF PROPOSED CARDHOLDER 4,000 2,000 10,000 50,000 BY SIGNING BELOW, I ASK FOR A CARD ACCOUNT TO BE OPENED AND CARD(S) TO BE ISSUED TO ME FROM TIME TO TIME UNTIL THE CARD ACCOUNT IS TERMINATED. UPON YOUR ACCEPTANCE OF THIS APPLICATION, WHICH MAY BE COMMUNICATED TO ME OR THE CORPORATE APPLICANT, I AGREED TO BE BOUND BY THE CITIBANK PURCHASING CARD AGREEMENT, A COPY OF WHICH IS AVAILABLE FOR INSPECTION WITH THE CORPORATE APPLICANT AND WHICH I HAVE READ AND UNDERSTOOD FULLY. I WARRANT THAT THE INFORMATION FURNISHED IN THIS FORM AND IN ANY DOCUMENTS OR ATTACHMENTS GIVEN TO YOU IN CONNECTION WITH THE APPLICATION BY ME OR THE CORPORATE APPLICANT IS TRUE AND ACCURATE. I TICK ONLY 1 LEVEL
A
FOR BANK USE
BC MCC
AUTHORISE ALL PERSONS/ENTITIES AS YOU MAY DEEM APPROPRIATE TO REQUEST FOR ANY INFORMATION (CONFIDENTIAL OR OTHERWISE) RELATING TO ME IN ANY WAY, TO RELEASE THE SAME TO YOU WITHOUT REFERENCE TO ME. I CONSENT TO YOUR DISCLOSURE TO ANY THIRD PARTY AS YOU DEEM FIT AT YOUR ABSOLUTE DISCRETION ANY INFORMATION RELATING TO ME IN ANY WAY. I CONFIRM THAT THE WARRANTIES
MERCHANT CATEGORY CODE CONTROL
AND AUTHORISATIONS ABOVE SHALL BE RELIED ON FOR THE PURPOSE OF ASSESSING THIS APPLICATION AS WELL AS FOR THE CONTINUING OPERATION OF THE CARD ACCOUNT. I AUTHORISE YOU TO PRINT AND/OR EMBOSS MY NAME AS SET OUT ABOVE ON THE CARD. I AGREE TO NOTIFY YOU IMMEDIATELY OF ANY
MERCHANT CATEGORY GROUP(S) SELECTED GROUP 1 GROUP 2 GROUP 3 GROUP 4 GROUP 5
CHANGE RELATING TO MY EMPLOYMENT/APPOINTMENT WITH THE CORPORATE APPLICANT. SIGNATURE OF PROPOSED CARDHOLDER
APP ID DP: Y / N NFNL: Y / N ALTERNATE CUSTOMER NUMBER VPC ACCOUNT NUMBER
A
D VE: Y / N NZII: Y / N
C
BC
DATE NOTE:
MASTER CUSTOMER NUMBER MASTER CARD NUMBER CORP CUSTOMER NUMBER
Co. Reg. No: 200309485K
CITIBANK HAS A RIGHT TO REJECT ANY NOMINATION OF A PROPOSED CARDHOLDER WITHOUT FURNISHING REASONS. CITIBANK PURCHASING CARDS WILL BE ISSUED TO SUCCESSFUL PROPOSED CARDHOLDERS.