Request for an additional Citi Credit Card by ps94506


									                      Request for an additional Citi Credit Card
❏ Yes, I would like to share the advantages of my Citi credit card with my partner or a relative.

                                                                                                                                                                      REV 0511-E
Principal cardholder

First name

I would like an additional card

                                                                                                                                                                      Editor in charge: L. Brenard - 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.
linked to my Citi credit card with number :

for the following person :            ❏ Mr       ❏ Ms      ❏ Mrs


First name

Date of birth                                               Nationality

    Date :                                                                            Date :

    Signature of principal cardholder :                                               Signature of additional cardholder :

         ✗                                                                                ✗

                                                                                     Please enclose a recto/verso copy of the identity card
                                                                                             from the applicant of the add-on card.

Citi Visa and Citi MasterCard :                            Free                       Citi Euphony World MasterCard :               5,00 EUR
Citi Visa Gold :                                           Free                       Citi Extra World MasterCard :                 5,00 EUR
Citi Proximus Visa :                                12,50 EUR
Citi Neckermann World MasterCard :                  5,00 EUR
Citi MasterCard of Photo Hall :                    10,00 EUR
Citi Travel Pass World MasterCard :                20,00 EUR

Transactions carried out using the additional card, and if applicable the annual fee, shall be debited from the above-mentioned
account. This contract shall be subject to the same conditions as for the principal contract.

I wish to receive personalized offers ❏ by SMS ❏ by e-mail
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 detec-
tion of fraud and related crimes, producing statistics, management information and executing tests, 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 Citi affiliates, or with its service providers. Citibank 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.

                                      Please send this application form by fax to 0800/200 97
                          or by post to Citibank Cards - Boulevard General Jacques 263g - 1050 Brussels.

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