Application form for the American Express® Gold Card

Please share with us how you would like your name to appear on the Card

Maximum 24 characters

Yes, I want to apply for an Additional Card to separate different categories of expenditure.

The Annual Membership Fee for the American Express Gold Card is Rs. 3900/- plus taxes. It covers the Annual Fee for one Basic Card for the Card member, one
Additional Card, up to two Supplementary Cards and membership into Frequent Traveller Option of the American Express Membership Rewards Programme.
However, membership to the American Express Gold Card is complimentary for the first year which includes the Annual Fee for the Basic Card and up to two
Supplementary Cards.

All fields are mandatory

PERSONAL INFORMATION
Title: Mr. Ms. Other (Please specify):
Name:
First Middle Last
Gender: Male Female Date of Birth: D D / M M / Y Y Residential Status: Resident Indian Non Resident Indian

Nationality: Driving Licence/Passport No.: PAN No. :

Residential Address:

City: PIN:
Phone No. (Home): With STD Code Mobile No.:

Email: Education: Last University/College :

Marital Status: Married Single Residential Details: Own Home Rented Company Lease Other

Tenure at current address: Year Month

Vehicle Car: Brand/Make/Model: Where would you like to receive your statement? Office Address Home Address

OCCUPATION INFORMATION

Employment Status: Salaried Self Employed Organisation’s Name:

Industry/Nature of Business: Current Designation:

Office Address:

City: PIN:

Office Phone No. (Board): With STD Code Extn. No.: Office Phone No. (Direct): With STD Code

Years at Current Business/Organisation (For salaried only):

If you are self employed, please fill in the following details:- Turnover No. of Employees Years in Business Net Profit

FINANCIAL PARTICULARS

Gross Annual Income: Signature:

Principal Bank Name: Type of Account: Savings Current Others

Account No.: No. of Years Account Held: Year Month

Other Financial details (In Rs.) Mutual Funds Shares Insurance Others:

Please Turn Overleaf

 CREDIT CARDS/ LOANS OWNED
Issuer/Bank: Card No.:
Credit Limit: No. of Years Held:

Issuer/Bank: Card No.:

Credit Limit: No. of Years Held: Existing Relationship with us: American Express Card American Express Service Establishment
Existing Card/Merchant No.:

Loan Account Number (if any) Bank name from where loan is taken

Type of loan: Auto Home Personel Other

SUPPLEMENTARY CREDIT CARD

Supplementary Credit Card 1* (Supplementary Credit Card member must be over 18 years of age) Supplementary Credit Card 2* (Supplementary Credit Card member must be over 18 years of age)
Mr. Ms. Other (Please specify): Mr. Ms. Other (Please specify):
Name as desired on the Card: Name as desired on the Card:

Name: Name:
First Middle Last First Middle Last
Date of Birth: D D / M M / Y Y Date of Birth: D D / M M / Y Y

Family relationship with Basic Credit Card member: Family relationship with Basic Credit Card member:

*Up to two Supplementary Cards may be issued to your Card Account at no extra cost. The Annual Membership Fee for the third Supplementary Card onwards is Rs. 1500/- plus applicable taxes for each Card. In case you wish to
apply for more than two Supplementary Cards, please call the Gold Card services helpline after you have recieved your Basic Card membership.

TELE-MARKETING COMMUNICATION

Yes, I agree to receive all marketing communication and offers on my American Express Gold Card through telemarketing channels notwithstanding my telephone
number being registered in any Do not call registry list. I understand I can withdraw my consent at any point of time by registering with the American Express Do Not Call
Registry by calling the Helpline numbers mentioned at the back of the Card.

Signature:

INCOME DOCUMENTS REQUIRED

These documents are mandatory and copies submitted need to be self attested by the applicants:
a. For Salaried - Latest Form 16/personal Income Tax return acknowledged by I.T.O. OR Latest Salary Certificate/monthly pay slip from employer with the break up or Latest
Salary Certificate/monthly pay slip from employer with the break up and a copy of company ID proof. (the Salary Certificate/monthly pay slip is accepted only if
employed with a Government, Public Limited or a Multinational company)
b. For Self Employed - Latest personal Income Tax return acknowledged by I.T.O.
c. Identity proof (eg. passport, driving licence etc.) and residential proof (eg. phone bill, electricity bill, passport etc.)
d. Visiting Card
e. Photo ID proof of Supplementary Card member indicating date of birth.
f. Please provide seperate document supports for ID proof and address proof

CARD MEMBER UNDERTAKING AND SIGNATURE

I/we, confirm and warrant that the above information is true and correct and by signing this form, I/we above request that an American Express Gold Card Account(s) be opened for me/us and for American Express Gold Card
(“Card(s)”) to be issued as requested (including renewal and replacement of Card(s)). I/we authorize American Express Banking Corp. (”AEBC”) to verify information in this application and to receive and exchange information about
me/us, including requesting reports from my/our Bank, consumer credit, reference schemes or credit bureaus and CIBIL. I/we authorize AEBC and its affiliates to contact these sources for information at any time, to use information
from this application and from consumer credit reports, for marketing and administrative purpose and to share such information with each other. If and when the Card(s) is/are issued to me/us, I/we declare and undertake that
the Card(s) issued to me/us, if used overseas, shall be utilised strictly in accordance with the relevant exchange control regulations issued and as amended by the Reserve Bank of India (“RBI”), from time to time. In the event that
I/we exceed my/our entitlements as per the Exchange Control Guidelines of the RBI, I/we undertake to bring the same immediately to the notice of AEBC, in writing. Obtaining any approval from RBI for excess foreign exchange
spending shall be my/our responsibility and I/we undertake to ensure strict compliance of the prevailing Exchange Control Regulations. I/we understand that the Basic Card member will be liable for all charges incurred on the
Basic Card, any Additional Card(s) and any/all Supplementary Card(s). The Supplementary Card member accepts joint and several responsibility for all charges incurred on the Supplementary Card issued to him/her. I/we agree to
be bound by the Card member Terms and Conditions of use, which will accompany the Card(s). I/we confirm that American Express has shared the Most Important Terms and Conditions (“MITC”) for the American Express
Gold Card, with me/us in compliance of the RBI master circular on Credit Card operations of banks and I/we have read, understood and accept the MITC and agree to sign this undertaking. I/we understand that AEBC may decline
this application at its absolute and sole discretion.

Basic Applicant’s Signature: Date:

Source Code: MR Code: MUD Code: ST Code:

 ECS ENROLLMENT FORM
FORM A
To
American Express Banking Corp.
Cyber City, Tower C, DLF Bldg. No.8
Sector-25, DLF City, Phase-II
Gurgaon-122 002

Dear Sir,
Re:       AUTHORISATION TO PAY CHARGE CARD BILLS THROUGH THE ELECTRONIC DEBIT CLEARING SYSTEM*

 1.      Name:
2.      Card Number: 3 7 6 9 1
3.      Particulars of Bank Account
a)      Name of Account Holder: b)      Bank Name: c)      Branch Address:
d)      9 digit code number of the bank and branch appearing on the MICR cheque issued by the bank:
(Please attach a cancelled blank cheque or its photocopy)

e)      Account type: f)       Ledger Folio Number:

(Savings/Current/CC Account) with code 10/11/13 (If appearing on the cheque book)

g)      Account Number:

(As appearing on the cheque book)

Yes, I have attached a cancelled blank cheque or its photocopy

Signature of Account Holder  :                                                Date:

*For Bank Account in Delhi, Mumbai, Chennai, Bengaluru and Kolkata only.

FORM B

I, the undersigned hold a Charge Card.

I understand that “Charge Card means any Basic Charge Card issued by American Express that has the trade mark, or logo or service mark, or the name American Express either
in conjunction with any other name or otherwise on the face of it.
I wish to avail of the Direct Debit facility and hereby express my unconditional consent to debit payment of the amount of the monthly bills of my Card Account (or of any
replacement/renewal Card that may be issued on the Card Account in lieu thereof) through participation in the Electronic Clearing System (ECS) of the National Clearing
Cell of the Reserve Bank of India.  I also unconditionally and irrevocably authorize American Express Banking Corp. (AEBC) to raise debits for such regular payments against
my
Bank Account Number                                                , with                                       Bank.
I hereby declare that the particulars given above are true and complete.
If the transactions based on my above instructions are delayed, or are not affected for any reasons whatsoever, I agree not to hold AEBC responsible for any loss/
damage/inconvenience that may arise.
I agree and understand that may bank shall be informed of this authorization as per the enclosed letter. Also, I understand that the above instructions cannot be withdrawn/cancelled
except after due intimation and with the written consent of AEBC for the payment of the Card dues.

Signature of Account Holder  :                                                Date: Note: Please complete in all respects.

FORM C
To

The Manager: Bank Name:

Bank Address:

 Dear Sir,

I, the undersigned hold an American Express Card and wish to avail of the Electronic Clearing System offered by the Reserve Bank of India towards settlement of my monthly
Card bills.

I have a Bank account having Account Name Account Number with your Bank. I hereby
authorize you to debit month on month, to my above mentioned account, my monthly dues on my Card as raised by American Express Banking Corp. (AEBC).

I further request you to inform AEBC of any changes in the status of my account. Once the American Express Card gets renewed for membership, the ECS facility attached
to the Card will get automatically renewed.

Start Date - The date of signing the form

End Date - Till revoked by me in writing to American Express Banking Corp. and to you.

Signature of Account Holder  :                                                Date: Copy of cancelled cheque attached

 DETAILS FOR CARD MEMBERS SIGNING UP FOR STANDING INSTRUCTIONS WITH BILLDESK

Name of the Card member: Date of Birth:

As it appears on the Card

Address: City:

PIN: Mobile No*: Email*:

*To ensure timely communication on the status of your application, please fill in your mobile number and email ID. Forms without mobile number will not be registered.
• Please continue to pay your bills until you receive confirmation from BillDesk regarding the activation of your Standing Instructions
• For any enquiries, please contact BillDesk at 022-40920015 (between 9:30am and 6pm, Monday to Saturday) or e-mail Customer Support Desk at acard@billdesk.com

STANDING INSTRUCTIONS FOR SERVICE PROVIDERS

PLEASE ATTACH RECENT COPY OF THE SERVICE PROVIDERS’ BILLS

√ Yes, I would like to earn Membership Rewards Points by giving Standing Instructions for the below mentioned Utility Service Providers to be charged to my
American Express Gold Card.
MOBILE & LANDLINE

Utility Company: Utility Company:

Airtel Airtel
Reliance Telephone no: Reliance Telephone no:
Vodafone Cust ID/Account no: Vodafone Cust ID/Account no:
Tata Indicom Tata Indicom
Idea Subscriber name: Idea Subscriber name:
Loop Mobile Loop Mobile
Spice Telecom City: Spice Telecom City:
Opt-Out Opt-Out

Utility Company: Utility Company:

Airtel Airtel
Reliance Telephone no: Reliance Telephone no:
Vodafone Cust ID/Account no: Vodafone Cust ID/Account no:
Tata Indicom Tata Indicom
Idea Subscriber name: Idea Subscriber name:
Loop Mobile Loop Mobile
Spice Telecom City: Spice Telecom City:
Opt-Out Opt-Out

INSURANCE

Insurance Company: Insurance Company:

LIC LIC
Reliance Life Policy no: Reliance Life Policy no:
SBI Life SBI Life
Premium Amount: Premium Amount:
Tata AIG Life Tata AIG Life
ICICI Prudential Client ID (For AVIVA/Birla Sun Life): ICICI Prudential Client ID (For AVIVA/Birla Sun Life):
AVIVA AVIVA
Birla Sun Life Policyholder name 1. For Bharti AXA: Birla Sun Life Policyholder name 1. For Bharti AXA:
Bharti AXA 2. ICICI Prudential: Bharti AXA 2. ICICI Prudential:
Opt-Out Opt-Out

Insurance Company: Insurance Company:

LIC LIC
Reliance Life Policy no: Reliance Life Policy no:
SBI Life SBI Life
Premium Amount: Premium Amount:
Tata AIG Life Tata AIG Life
ICICI Prudential Client ID (For AVIVA/Birla Sun Life): ICICI Prudential Client ID (For AVIVA/Birla Sun Life):
AVIVA AVIVA
Birla Sun Life Policyholder name 1. For Bharti AXA: Birla Sun Life Policyholder name 1. For Bharti AXA:
Bharti AXA 2. ICICI Prudential: Bharti AXA 2. ICICI Prudential:
Opt-Out Opt-Out

ELECTRICITY

Utility Company: Utility Company:

Cust ID/Cons no/CRN: Cust ID/Cons no/CRN:
BSES BSES
NDPL Cycle no (Rel): NDPL Cycle no (Rel):
Reliance Energy Billing unit (MSEB): Reliance Energy Billing unit (MSEB):
MSEB## MSEB##
MGL## Processing cycle (MSEB): MGL## Processing cycle (MSEB):
BEST BEST
Subscriber name: Subscriber name:
TATA POWER TATA POWER
City: City:
Opt-Out Opt-Out
#
Electricity: Standing Instruction available only for Low Tension connections. ##2.5% surcharge applicable on MSEB & MGL
 (For American Express Use only)

American Express Gold Card No.: Expiry Date: M M / Y Y

I authorize American Express to write my Card details in the box above on my behalf, and share the same with BillDesk (“Service Provider”) for enrollment into the Standing Instructions.
I also authorize and express my unconditional consent to the Service Provider for debiting my American Express Card Account (or of any renewal/ replacement Card that may be issued in
the Card account in lieu thereof) on a recurring basis with the full amount of all charges including the monthly bill and any interim charges pertaining to my utility connection (the reference/
customer/relationship number as stated above in the form). I have read, agreed and understood the terms as provided alongside and voluntarily and unconditionally undertake that:
• This Standing Instruction will be effective for the full amount and shall apply only if my American Express Card Account (“Card”) is valid and in good standing • The Service Provider may at
its sole discretion accept or decline this Standing Instruction as provided by me • My Standing Instruction is in respect of the entire charges on my utility service/connection and the said
instruction shall be valid and binding for the validity period and subsequent renewal period of the Card unless and until the same has been rescinded by me in writing and the said communication
has been received by the Service Provider • I hereby authorize BillDesk and American Express to exchange/compare information pertaining to my Card. Resultantly, the Service Provider may
receive from American Express updated information on my Card including but not limited only to changes in Card numbers, expiration dates and status. I understand and am cognizant of the
fact that the results of such exchange/comparison may also be used by the Service Provider and/or American Express for the purpose of taking any action, including adverse action against
me • The record of charges in respect of the above services received or availed by the Service Provider to the Card will neither bear my signatures nor the imprint of my Card. I therefore
undertake to unconditionally honor and pay without demure and contestation all the said charges including interim charges booked by me under this facility as and when I am billed for the
same by American Express • The Service provider will continue to send me bills at regular frequency for the above utility service/facility as per the normal process • I will continue to make
payments toward my utility service until I receive a confirmation from BillDesk that my service request has been activated.

Basic Applicant’s Signature: Date:

Terms & Conditions

• Standing Instruction for direct debit to American Express Card Account (“Card”) will be for the full amount shown on the monthly bill inclusive
of all interim charges levied by the Service Provider/Utility Company for the utility connection of the American Express Card member
(“Card member”) • It is clear that American Express is only a facilitator and a mode of payment for the Card member and is not responsible or liable
for any omissions or commissions with regard to the acceptance of the Standing Instruction forms for and on behalf of the Service Provider • Signing
of the Standing Instruction form by the Card member and payment of the first Service Provider bill will be sufficient proof to establish the authenticity
of the Card member instruction to debit his/her Card with the monthly bill and any interim charges for his/her utility connection • All such charges
to the Card are subject to authorization by American Express. In case of transactions being declined, the Card member is required or is liable to
make the payment by alternate means, such as cash/cheque, failing which, the Service Provider could restrict the utility connection facilities/services
• American Express reserves the right to revoke/stop the facility if the credit behaviour on the Card is unsatisfactory or if it believes that continued
use of this facility is not in interest of the Bank • It would be the responsibility of the Card member to inform BillDesk, in writing, of any change
or withdrawal of the BillDesk facility thus availed. Failure of the Card member to do the same and subsequent debits, if any, towards the utility
payments will constitute valid transactions and the Card member will be liable to pay the same • Card member is required to fill a revised
Standing Instruction form in case of any change in Card number due to replacement upgrade or downgrade • American Express is neither responsible
nor guarantees the quality of services and nor is it liable for any defect or deficiency in the said services so obtained/availed and shall also not
by be liable for any loss/damage/claim that may arise out of the use or non use of any such services availed by the Card members. American Express
and BillDesk reserve the right to change/alter/modify/withdraw the offer, utility companies or the Terms and Conditions of this program, at any
time, without prior notice • Nothing expressed or implied in the offer shall any way waive or amend any of the Terms and Conditions of the existing
Card member agreement • Any disputes arising out of disconnection of the Utility/Facility, penalty from the government and late charges on
installment dues arising due to change/revocation of the facility will be the sole responsibility of the Card member and the Card member will not
hold American Express responsible for the same • All disputes arising out of this program shall be subject to the exclusive jurisdiction of competent
courts in the State of Delhi.

Facility of Opt-Out Option

This is a Standing Instruction for automatic monthly debit of Utility Bill/s payment with a facility to Opt-Out in case the Card member does not
want any particular bill to be charged on his American Express Card (Card). The Card member will receive an SMS before the bill due date, detailing
the amount of the bill that will be debited to the Card. The Card member would have to revert to the SMS in the specified format and within
the mentioned time frame to stop processing of that particular payment on the Card, should the Card member desire to Opt-Out. In the absence
of revert from the Card member, the bill will be automatically charged to the Card account.
RCPGLD/042010