AMERICAN EXPRESS® GOLD CREDIT CARD APPLICATION FORM

H S 6 1 3 REFERENCE
(Parents/immediate family members not living with you
American Express Gold Credit Card : Lifetime Fee Waiver
To qualify, applicants must be 21 years old or above for Basic Cardmember, and 18 years old or above for Supplementary Title Mr Mrs Ms
Cardmember. Age limit for applicants is 65. Name

PERSONAL DATA Relationship

Home Address
Title Mr Mrs Ms
Full name as in NRIC or Passport
Postcode

NRIC No. (New) – – Home Tel

NRIC No. (Old) Office Tel

Passport No. Mobile No.

Nationality
SUPPLEMENTARY CARD
Date of Birth – –
Title Mr Mrs Ms
Name to appear on card (maximum 19 characters)
Full name as in NRIC or Passport

View my American Express Gold Credit Card Statement on www.maybank2u.com and email.
Name to appear on card (maximum 19 characters)
Email ID

I want my statement to be mailed to me at RM5 per month. Applicable for American Express NRIC No. (New) – –
Gold Credit Card.
NRIC No. (Old)
Present Home Address
Passport No.
Nationality
Postcode
Date of Birth – –
Home Tel Relationship to Principal Cardholder
Mobile No.
Mother’s Name View my American Express Gold Credit Card Statement on www.maybank2u.com and email.
(This feature is for your security when verification is required.
Email ID
Residence Own Parents
Others Relatives I want my statement to be mailed to me at RM5 per month. Applicable for American Express
Gold Credit Card.
Years spent
(If other than Principal Cardholder’s address.)
Marital Status Married Single
Home Address
Postcode
EMPLOYMENT DETAILS
Home Tel
Company’s Name Office Tel
Office Address Mobile No.

Postcode
DECLARATION
General Line
Direct Line I/We further agree and authorise the Bank to make the relevant credit references with external parties
including but not limited to CCRIS, FIS, CTOS and any other credit reference agencies and that in so
Position doing the Bank shall be entitled to disclose such information as may be necessary in order for the external
parties to provide the Bank with the references/confirmation sought.
Business Classification
I/We declare that the information given by me/us is true and complete. I/We hereby authorize you
Sole Proprietorship Partnership to verify information on me/us and any supplementary applicant(s) from whatever source you consider
Government Sdn Bhd appropriate from any financial institution and the Director General of Inland Revenue Department on
any information which Malayan Banking Berhad may require. I/We also confirm that none of my/our
MNC / Public Listed Others spouse(s), parents and/or children are employees of Malayan Banking Berhad or Malayan Banking Group.
I/We confirm that I/we shall read the Terms and Conditions of the Maybankard American Express
Years Employed/In Business Charge Card Agreement and agree to be bound by them and all future amendments thereto before
accepting and receiving the card(s). I/We further agree that the Principal Cardmember shall be responsible
Annual/Business Income RM for all liabilities and obligations of the Principal Cardmember as well as those of the Supplementary
Other Income RM Cardmember(s). The Supplementary Cardmember however, shall only be responsible for his/her own
liabilities and obligations. The Bank shall reserve the absolute right to approve or reject my/our application
(Please enclose supporting documents.
as The Bank deems fit without assigning any reason. I/We understand the card(s) remain the property
Sources / Sumber of Malayan Banking Berhad and shall be subject to cancellation without notice and would be returned
upon request. I/We hereby agree to you disclosing information to Bank Negara Malaysia regarding
Name of previous employer (if less than 1 year in present employment) my/our credit facilities and my/our account with you, as may be required, whether pursuant to law or
otherwise. Malayan Banking Berhad shall not be liable whether directly or indirectly to me/us or any
other persons for such disclosure.
Years There (For External Account Holders Only)
I/We confirm that my /our borrowings from all sources within Malaysia do not exceed in aggregate of
Previous Position
RM200,000.
You are Salaried
Self Employed - BRC No. if you are self-employed Principal Cardholder

BANKING REFERENCE Signature Date

Bank A/C No. Type of A/C Date Opened

Supplementary Cardholder

Signature Date