CARDHOLDER APPLICATION FORM
PERSONAL DETAILS First Name: Last Name: Name to appear on the card (Max 19 Characters, no special characters or accents) Male
Female
Passport
Date of birth: (mm/dd/yyyy)
National ID
/
/
Driver’s License
Nationality: Address (Street):
City:
Country:
ZIP Code:
Home phone number:
Mobile number:
Email: Marital status: Married Residential status:
Owner
Single
Other
Renting
Other
SHIPPING ADDRESS Personal Address
Work Address
Other
Address (Street):
City:
ZIP Code:
Country:
Home phone number:
Mobile number:
Delivery method:
Standard Post
Courier (Costs apply)
ACKNOWLEDGMENT I hereby certify that the information contained in this application is correct, accurate and complete. You are hereby authorized to obtain any confirmation you may require about the details provided from my employers and/ or other bankers/lender in order to consider this application. I confirm that I have read, understood and accept to be bound by the terms and conditions which I find reasonable, fair and necessary for me to acquire the card. Having familiarized myself with the bank charges related to this card program, I will not dispute any claim by the Program on the grounds that the charges are unfair and unreasonable under any circumstances. I shall keep the card secured at all times and report any loss/theft/ misplacement to the Program Center immediately. I agree to be liable for all debits to the card account, balance inquires shall be offered on the ATM and/or telephone upon identification, and statement requests shall bear a fee. Applicant’s Signature:
Date:
REQUIRED DOCUMENTATION Please include color scan/copy of two of the following: 1. Identification:
2. Proof of Address – Not older than 3 months:
Passport
Utillity Bill (Gas, Electric, Cable,) Mobile)
National ID (if in another language please provide Translation)
Bank Statement
Driver’s License (must include picture and expiration date)
CAPITAL SECURITY BANK LIMITED 1