Small Business Agreement (CCS-SB) Company Application Jean-Eric Lemelin Source Code: 3574
Diners Club International 630, René-Lévesque W., 13th Floor Montreal, QC H3B 4Z9
Instructions: 1. Company Officer completes Company Application on behalf of the Company. 2. Each individual to receive a Card, including Company Officer, completes a Cardmember Application and agrees to Diners Club Terms and Conditions [attached or on the reverse]. Up to 10 applicants permitted. 3. Company Officer returns Completed Company Application and all Cardmember Applications to the address above.
Annual fee: $35 for each applicant. Do not send annual fee at this time, as we will bill you later.
Customer Information (
Company Name Company Billing Address—Street Company Billing Address—2nd Line City Years in Business Province Postal Code Nature of Business $ Yes No
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Company Telephone
Company Fax
Company Primary Bank Name Branch Address—Street Branch Address—2nd Line City Province Postal Code
Anticipated monthly spending on Card: Does your Company accept Diners Club for payment?
Company Bank Account Number:
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Branch Officer Name
Branch Telephone
Your Choice Of Optional Travel Accident Insurance
In addition to the basic Travel Accident Insurance* coverage of $300,000, the Diners Club Small Business Card offers you these options: Total Coverage Cost Per Trip Insure me for the initialed option Insure supplementary applicants for the initialed option
A. $ 500,000 B. $ 750,000 C. $1,000,000 Company Signature
$ 2.50 $ 5.00 $10.00
Company Officer signing this application on behalf of the Company must be one of the following: President Owner/Partner Vice President Treasurer
By signing below, the Company (a) certifies that the information provided on this form to be true and accurate, (b) acknowledges that it accepts in full the Diners Club Terms and Conditions [attached or on the reverse] and (c) authorizes and consents to the receipt and exchange of credit information about the Company by Citibank Canada.
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Company Officer Signature
Company Officer Name (print)
Date
Please note: Company Officer must also complete a Cardmember Application in order to receive a Card.
* All insurance coverages are underwritten by Chubb Insurance Company of Canada, and administered by WorldNet Services Corp. Certain limitations, conditions and exclusions apply.
Small Business Card Application Terms and Conditions
By signing this application, the Company, Company Officer and the employee applicant (a) request that an account be opened in the name of the Company, (“Account”) (b) request that Diners Club Small Business Card(s) be issued on the Account as requested on this and other Small Business Card applications. Signers agree that each Card issued as a result of this application will be governed by the Cardholder Agreement provided at the time the Card is issued. The employee applicant agrees to be jointly and severally liable with the Company Officer and the Company for all charges placed on the Small Business Card issued to him/her. The Company and Company Officer agree to be jointly and severally liable with each employee applicant for all charges to all Small Business Cards issued under the Account. By signing this application, the Company Officer and each applicant agree to be bound by the terms and conditions of the Agreement governing the use of the Small Business Card. The Agreement will be sent with the Card to each person designated by the Company to issue a Card and who has signed a Small Business Card Cardmember Application. If an amount is past due for two billing cycles, late interest at 2 ½% per month, or a nominal rate of 30% per annum, will be charged on all past due amounts and added to the Card account balance. 1. Balances are due in full each month. However, there is a period equal to two billing cycles before late interest is assessed. Individual billing cycles vary, two billing cycles range from 52 to 62 days. Spending patterns are based on the individual’s payment and spending pattern. Insurance coverages are underwritten by Chubb Insurance Company of Canada and administered by WorldNet Service Corp. Certain limitations, conditions and exclusions apply. Emergency Travel Assistance Services provided by WorldNet Services Corp. Due to the factors of distance, information and communications, neither Diners Club nor WorldNet can assume responsibility for the availability, quality, use or results of any emergency services. All services and coverages are subject to change without notice. Club Rewards points are earned on all purchases less credits. Cash advances, fees, late charges and payments do not qualify for Club Rewards points.
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Benefits are subject to certain terms and conditions. Specific benefits and rewards are subject to availability and may be changed or discontinued without notice.
Before you sign…
PRIVACY: Citibank Canada and its affiliates, service providers, successors and assigns (collectively, “Citibank Canada”) will collect from you, or from third parties, and may use and disclose your personal information for the following purposes: (i) to make decisions about applications; (ii) to monitor, evaluate credit worthiness, service and collect your account; (iii) to respond to your inquiries about applications, accounts or other services; (iv) to understand your needs and to offer products and services to meet those needs; (v) to allow our subsidiaries, affiliates, and selected other companies to promote their products and services to you; (vi) to meet legal, security, processing and regulatory requirements. You may refuse or withdraw your consent to item (v) by writing to us. Before using your personal information for any purpose other than those listed in (i) to (vi) above, we will explain that purpose to you and seek your consent. Write to this address to (1) file an opt-out request; (2) request access to your file; (3) report incorrect information; (4) file a privacy complaint; and /or (5) receive further information about our privacy policies: Diners Club, P.O. Box 740, Station B, Montreal, Quebec, H3B 4Z2, c/o Privacy Officer. [You can also call 1 800 363-3333 or visit us at www.dinersclubca.com for more information about Citigroup’s global Privacy Promise.]
Diners Club, Diners Club International, Reg. TMs of Diners Club International Ltd. enRoute, Aeroplan, Reg. TMs of Air Canada. Citibank Canada is an authorized user of the marks.
Small Business Agreement (CCS-SB) Cardmember Application Jean-Eric Lemelin Source Code: 3574
Applicant ( ): Last Name Home Address City Province Mr. Mrs. Ms. First Name
Complete and return with Company Application
APPLICANT INFORMATION (for additional names, copy this form and submit with Company Application)
Postal Code Social Insurance Number (optional)
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Date of Birth CLUB REWARDS
Yes! Please enroll me in the Club Rewards Program from Diners Club and start awarding me Club Rewards points on all eligible transactions charged to my Card. Points can be redeemed for Air Canada Aeroplan miles, merchandise, and more. I understand that an annual fee of $85 (plus applicable taxes) will be charged to my Card Account.
Aeroplan Number (if applicable): APPLICANT SIGNATURE
Diners Club Card Number (if applicable):
By signing below, I (a) certify that the information provided on this form to be true and accurate; (b) acknowledge that I have read, understood and accept in full the Diners Club Terms and Conditions [attached or on the reverse]. I authorize and freely consent to the collection, use and disclosure of information about me by Citibank Canada for the purposes set out under the heading “Privacy” [attached or on the reverse], including, without limitation, the receipt and exchange of credit and personal information about me by Citibank Canada with any credit reporting agency, personal information agent, credit bureau and any person or corporation with whom I have or may have financial relations. / / Date
Signature of Applicant (
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Please Note: Every Applicant must read and accept the Diners Club Terms and Conditions. A copy of the Terms and Conditions should accompany each Application.