Citi M Supplementary Card Applic by ps94506

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									        Citi M Supplementary Card Application                                               Return this application to Fax#: 02-232-4112

                                                         Supplementary Card Application

 S.C.             Internet                AGT.                               Card Type                                      Supplementary Card

 Information of Basic Cardholder: Name                                                      Last Name

 ID/Passport Number              --              --                 --                        Tel:

 Citibank Credit Card Number:                    --           --               --

 Information of Supplementary card applicant:
 Name                                                   Last Name                                           Nationality

 Name in Passport:                        Mr.    Mrs.   Ms.

 Date of Birth:              /        /                            ID/Passport Number:        --              --                  --

 Address:

 Tel:                                                                    Relationship with Basic Card

                                                         Covenant and Representative

I/We (including the basic card applicant/authorizer/the supplementary card applicant) who have asked and/or have had facility/credit card
with Citibank, N.A., Bangkok branch (the “Bank”) agree and consent the Bank to ask, check, record, change, correct, reveal and/or do any
manner related all my/our credit data and/or other data (hereinafter collectively called the “Data”) to recorded at the National Credit Bureau
Co.,Ltd and/or all data companies which the Bank holds the membership therewith (hereinafter collectively called the “Credit Data
Company”), the Bank, CITI’s entities, The Mall Group Co.,Ltd., City Mall Group Co.,Ltd. (hereinafter collectively Called ”The Mall Group”) the
Bank’s representatives, auditors, other financial institutions together with any organization, government sector, the Bank’s assignee(s), any
juristic person and/or any person which the Bank is a contractual party or has any business relationship therewith. l/We further
consent/authorize the Credit Data Company, the Bank, The Mall Group, the said juristic person and/or any person to disclose and/or do
manner related all my/our Data for the purposes of credit analysis and the grant of credit/credit card(s), including any subsequent disclosure
or giving of my credit information for the purpose of credit review, renewal of credit agreements and credit card agreements, or risk
management and prevention pursuant to the Bank of Thailand’s stipulations, in relation to all or any of my credit/loan/credit card accounts
with any member and/or service user of the Company, without having to request my re-consent. I further agree that any duplication and
copy, electronic data or facsimile of this letter of consent which have been made by means of photocopying, scanned image or record in
whatever forms shall be deemed as evidence of my consent with the same effect as its original. I/We, also, agree and consent the Bank to
issue, renew or reissue credit card, increase/ decrease/change/ transfer/review credit line to me and/or to supplementary card applicant(s)
unless I/We and/or the supplementary card applicant(s) cancel the card in a manner specified by the Bank and/or until the Bank cancels the
card. I/We agree to be bound and comply with all terms and conditions of all services provided by the Bank thru AVR system/internet/any
other electronics methods including all regulations in relation to the card together with any amendment to be made thereafter which the
Bank may inform me/us. I/We shall bear all liabilities from the both basic card and supplementary card and (s) I/We agree to take liability as
the joint debtor for any debts, charges, fees and expenses arising out of or in connection with holding and/or using of the card until the
same is paid to the bank in full. The consideration and approval of the application are subjected to the internal criteria/term of the Bank and
the Bank reserves the right not to turn the application and all submitted materials including the NCB consent letter which i/we used to
submit or will submit to the Bank for applying the Bank products and/or service. I/We agree that the consent letter shall be prevail unless
I/We terminate or cancel all products and/or services, I/We undertake and warrant that the above information shown in the application and
my/our related documents and information at the moment and/or in future are true and correct. I/we may be contacted by third party
service provider who is appointed by Citibank to carry out collection activities in relation to any account in default of payments. In such case,
I/we will be charged the collection fee maximum of Baht 225 per statement cycle.


  Signature/ Authorizer/ On behalf of the Supplementary Card Applicant


                                                                                    Date
                                                                                                   Return this application to Fax#: 02-232-4112

                                   CONSENT FOR DISCLOSE CREDIT INFORMATION VIA FACSIMILE



                                                                                       Made at...........................................................................
                                                                                       Date................….............................................................




                                                                                  Conditions for giving consent via facsimile
 Instructions for giving consent via facsimile                                      Giving consent via facsimile is "electronic data" or is a clause
 1. Consent grantor must fill in the form correctly and completely                which has been made, sent, received, kept or processed by
      and sign its signature.                                                     electronic method which consent grantor is prohibited to refuse
 2.Consent grantor must attach copy of identification card                        the result, consequence, and enforcement by law of any clause
      which consent grantor must sign to certify true copy.                       just for the reason that such clause is in form of electronic
 3. Consent grantor may send facsimile by itself or may assign                    data.
      any person to send on behalf of consent grantor.
                                                                                    Giving consent via facsimile, therefore, shall be deemed as
                                                                                  giving consent according to the Credit Information Business Act
                                                                                  in every respect.




I, Mr./Mrs./Miss ………………………………………………………….…………. Last Name……………………………..……………………..

Date of Birth (DD/MM/YY) ……………………………………………..…………Telephone No………………………………..………………

     Identification Card          No.       --                    --                          --


Foreigner:

     Passport          No. …………………………….……………….……….…

     Other (please specify) ……………………………………………..…….. No. …………………………………………………………….



This consent has been made by voluntariness of mine and to send to the National Credit Bureau Co., Ltd. (the company) via facsimile as an
evidence that I hereby agree and consent to National Credit Bureau Co., Ltd. to disclose or to provide my credit information to Citibank, N.A. which
is member or service recipient of the company for the purposes of credit analysis, issuance of credit card according to my application for
credit/credit card, including to the purposes of credit review, credit agreement extension/credit card renewal, risk management and prevention
pursuant to the Bank of Thailand’s stipulations. I further agree that any duplication and any copy, photocopy, electronic data, or facsimile which
have been made as a copy from this original consent letter by means of photocopying, image scanning, or recording in whatever forms shall be
deemed as evidence of my consent with the same effect as its original.

In addition, before giving consent, I have been informed of instructions and conditions of giving consent via facsimile which is prescribed in the
head of this consent letter clearly.



    ………………..…………………………………………..                                                    ………………..……………………………………….
           (Consent Grantor)                                                                (Witness)



Remark: Credit information is one of the constituent for credit analysis of financial institutions but disclosure of such information is right of information
owner whether he/she will give it or not.

								
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