Request for a Citi credit card. - PDF

Document Sample
Request for a Citi credit card. - PDF Powered By Docstoc
					                                                                                           How can you sponsor one or more persons ?
                                                                                           • Print this application form and fill out accurately your personal data and the data of the person you
                                                                                             would like to sponsor. You then return this application to : Citibank Cards, Bld G. Jacqueslaan 263g,
Request for a                                                                                1050 Brussels or you fax it to 0800/200 97.
                                                                                           • You could also send a blank application form by email to the person you would like to sponsor. You then

Citi credit card.                                                                            ask this person to fill it out and return it to us. Do not forget to communicate your personal data to the
                                                                                             candidate and remind him to attach a photocopy of the front and the back of his identity card.

❏ Mr              ❏ Ms            ❏ Mrs                                   Citi credit card number                                           –                         –                     –

Surname                                                                                                                                                   First name


YES, I am interested in the advantages a Citi credit card with a credit opening can offer me. 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 without any commitment on my behalf.

Choose the credit card you want to apply for :                                               ❏                                                    ❏                                        ❏
For more information about
the different Citi credit cards,
visit                                                                                    Citi Visa                                    Citi MasterCard               Citi Travel Pass World MasterCard®


                                                                                                                                                                                                                                   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.
❏ Mr              ❏ Ms            ❏ Mrs
Surname                                                                                                                                            First name

Street                                                                                                                                                                             N°                       Box

Postal code                                          City/Town

Tel.                             /                                                                 Gsm                                /

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

Home :           ❏ Owner ❏ Lodger Since     year
                                                                                                             ❏ Family home
Name of my bank                                                                                                    Since

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            month
                           /            year
                                                                                                                                VAT-nbr if applicable : BE -

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
I hereby declare not being, and not being related to, a person who is or has been a Politically Exposed                                                     I certify that all information provided in this document is complete
Person(*). If this is not the case, I am ticking this box ❏                                                                                                 and accurate. By completing this document accurately, my applica-
(*)   If you would like to know the complete definition of a "Politically Exposed Person", please go to our website                    tion will be treated quickly and confidentially.

i wish to receive personalized offers ❏ by SMS ❏ by e-mail                                                                                                  Date :                      Signature mandatory :
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,
                                                                                                                                                           The credit card will be sent to my home address.
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 Citigroup affiliates, or with its
service providers. Citi 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.