Small Business Agreement (CCS-SB) Diners Club International
Company Application 630, René-Lévesque W., 13th Floor
Jean-Eric Le melin Source Code: 3574 H3B 4Z9
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
Annual fee: $35 for each applicant. Do not send annual fee at this ti me, as we will bill you later.
Custome r Information
( ) - ( ) -
Company Name Company Telephone Company Fax
Company Billing Address—Street Company Primary Bank Name
Company Billing Address—2 nd Line Branch Address—Street
City Province Postal Code Branch Address—2 nd Line
Years in Business Nature of Business City Province Postal Code
Anticipated monthly spending on Card: $ Company Bank Account Number:
Does your Company accept Yes ( ) -
Diners Club for payment? No Branch Telephone Branch Officer Name
Your Choice Of Optional Travel Accident Insurance
In addition to the basic Travel Accident Total Cost Per Insure me for Insure supplementary
Insurance* coverage of $300,000, the Coverage Trip the initialed applicants for the initialed
Diners Club Small Business Card offers you option option
A. $ 500,000 $ 2.50
B. $ 750,000 $ 5.00
C. $1,000,000 $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.
Company Office r Signature Company Office r 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
Small Business Card Application
Terms and Conditions
By signing this application, the Co mpany, Co mpany Officer and the employee applicant (a) request that an
account be opened in the name of the Co mpany, (“Account”) (b) request that Diners Club Small Business
Card(s) be issued on the Account as requested on this and other Small Business Card applicat ions. 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 emp loyee applicant agrees to be jointly and severally liable
with the Co mpany Officer and the Co mpany for all charges placed on the Small Business Card issued to
him/her. The Co mpany and Co mpany 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 Co mpany 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 Card member Applicat ion.
If an amount is past due for two billing cycles, late interest at 2 ½% per month, or a no minal rate of 30%
per annum, will be charged on all past due amounts and added to the Card account balanc e.
1. Balances are due in full each month. However, there is a period equal to two billing cycles
before late interest is assessed. Individual b illing cycles vary, two billing cycles range fro m
52 to 62 days.
2. Spending patterns are based on the individual’s payment and spending pattern.
3. Insurance coverages are underwritten by Chubb Insurance Co mpany of Canada and
administered by WorldNet Serv ice Corp. Certain limitations, conditions and exclusions
apply. Emergency Travel Assistance Services provided by WorldNet Services Corp. Due to
the factors of distance, informat ion and communicat ions, 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.
4. Club Rewards points are earned on all purchases less credits. Cash advances, fees, late
charges and payments do not qualify for Club Rewards points.
Benefits are subject to certain terms and conditions. Specific benefits an d rewards are subject to
availability and may be changed or discontinued without notice.
Before you sign…
PRIVA CY: Citibank Canada and its affiliates, service providers, successors and assigns (collectively,
“Citibank Canada”) will collect fro m you, or fro m third part ies, and may use and disclose your personal
informat ion for the fo llo wing purposes: (i) to make decisions about applications; (ii) to mon itor, evaluate
credit worth iness, 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 allo w our subsidiaries, affiliates, and selected other companies to promote their p roducts 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 (v i) above, we will exp lain 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 in formation; (4) file a privacy comp laint; and /or (5) receive further information about our privacy
policies: Diners Club, P.O. Bo x 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 informati on about
Citigroup’s global Pri vacy 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) Complete and return with
Cardmember Application Company Application
Jean-Eric Le melin Source Code: 3574
APPLICANT INFORMATION (for additional names, copy this form and submit with Company Application)
Applicant ( ): Mr. Mrs. Ms.
Last Name First Name
City Province Postal Code
Date of Birth Social Insurance Number (optional)
Yes! Please enroll me in the Club Rewards Program fro m Diners Club and start awarding me Club Rewards points on all elig ible
transactions charged to my Card. Points can be redeemed for A ir 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): Diners Club Card Number
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
Signature of Applicant ( ) Date
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.