Citibank Supplementary Credit Card Application Form

A Citibank Supplementary Credit Card (hereinafter: Supplementary Card) may be requested by a Main Cardholder
for his/her relatives, friends and acquaintances. The type of the Supplementary Card corresponds to the type of the
Main Cardholder’s card type. Any spending by the Supplementary Credit Card Holder (hereinafter Supplementary
Cardholder) and the fees of the Supplementary Card will be automatically debited from the Main Cardholder’s
account and information thereon will be sent in the account statement issued in the Main Cardholder’s name.
The Main Card Holder is responsible to reimburse all spending and costs realized with the Main Card and the
Supplementary Card(s), however, the Bank is entitled to enforce spending with the Supplementary Card sepa-
rately against the Supplementary Card Holder(s) also.
Basic conditions of application for a Citibank Supplementary Credit Card:
Minimum age of 14 years in case of Supplementary Card applicant. The Bank reserves the right to take other credit
assessment criteria, over and above the basic conditions of application, into consideration.
Determination of spending limit attached to Supplementary Card:
If you already have a Citibank credit card, you may determine the exact amount of the spending limit of the linked
supplementary card in the spending limit field relating to the Supplementary Card.
If you are applying for both a Main Card and a Supplementary Card, you will only be able to determine the exact
spending limit of the linked Supplementary Card upon the activation of the card as the approved amount of the
credit limit attached to the main card is not yet known at the time of the submission of the application.
Citibank Supplementary Credit Card Application Form
Cf 10/37 E
2/1. page
Application ID:
To be completed by the Bank
Personal details Please complete every field in ink and in block capitals!
Main Cardholder’s Citibank Credit Card number:
Main Cardholder’s name (as stated in identity card)*:
Supplementary Cardholder’s Surname (as stated in identity card)*:
Simultaneously with completing the present application form I apply for a Mobile Card to
Supplementary Card if it can be applied for with respect to this type of credit card.
Personal details of Supplementary Cardholder
First name(s)*:
Name at birth*:
Full name as you wish to have it displayed on the Supplementary Card (maximum 19 letters):
Sex: male
female Date of birth*: year/month/day:
Place of birth*:
Mother’s maiden name*:
National of which country?*:
Type of primary (1.) and secondary (2.) identification document*: identity card
passport driving license residence card other:
Number of identification document*: 1. 2.
Validity*: 1. 2.
Date of issuance*: 1. 2.
Issuing authority/country*: 1.
The Main Cardholder is your: spouse
parent child cohabitee
sibling other
Permanent residence
If you reside abroad, you have to complete the declaration of customer residing abroad.
Postcode: City:
: No.: Floor, door No.:
Type of the document that verify residence (compulsory field to complete when the secondary
identification document is not the residence card)*:
Home telephone number: +36
Primary mobile phone number
: +36
Additional own mobile phone number
: +36
Days / hours on/during which you may be called:
Primary e-mail address
Additional own e-mail address
It is obligatory to complete fields marked with *, other fields can be completed by consent
of the applicant.
I hereby accept that the Bank may inform me of its personalised offers, products and services by way of direct mar-
keting letters. Yes
I hereby accept that the Bank may send information regarding its products and services to this e-mail address and/or
mobile telephone number. Yes
My present consent/consents is/are voluntary and was/were granted in the light of the relevant information. The last
paragraph of the declaration provides for issues related to data management.
I hereby accept that, based on the Code of Conduct also signed by the Bank and Section 39, subsections (5) and (6) of Act
LXXXV of 2009 on Money Transaction Services, the Bank is entitled to send SMS text messages concerning my Contract
to the mobile telephone number stated.
I hereby acknowledge that the Bank sends to this mobile phone number or e-mail address provided all security codes
and notices related to all the products and services of the Bank. The mobile phone number and e-mail address stated in
this application override the e-mail address and mobile phone number previously provided with respect to any contracts
concluded with the Bank or to the use of other Service pursuant to the GBC.
Spending limit attached to Supplementary Card (need not be completed)
Citibank SMS Alerting service
I hereby accept that unless I make a negative declaration with respect to the Citibank SMS Alerting Service, by completing
and signing the present Application Form, I expressly request the Bank to provide the Citibank SMS Alerting Service on the
basis and under the terms and conditions of the GTC, GBC and the Conditions of Interest and Charges with respect to the
message types listed on the back of Page 2/1 of this Application Form, in the form of SMS text messages or e-mail. If you do
not wish to request the service, please state:
I do not request the Citibank SMS Alerting service
Citibank Online and the Citibank Mobile Banking services
The Bank makes available the Citibank Online and the Citibank Mobile Banking services to all Cardholders. The condition of
actual application and use of Citibank Online and Citibank Mobile Banking are registration by the Cardholder for the Citibank
Online service at the web site of the Bank and accepting the terms applicable to the service during registration. I am aware
that the CBOL Service is considered an electronic payment instrument.
If a contract is concluded hereby I request the Bank to continue to manage the data related to the contract and transferred
to the CCIS after the termination of the legal relationship for a period of five years.
yes no
Declaration under the legislation concerning the prevention of money laundering
Declaration under Section 8 of Act CXXXVI of 2007 on the Prevention and Combating of Money Laundering and Terrorist Financing.
I hereby declare that, for the purposes of the financial product/service stated in the present contract, I proceed as a natural person
on my own behalf
on behalf of the following person (actual holder.
Details of beneficial owner (to be completed only in case of second alternative):
First name(s) and surname:
Name at birth if different:
I hereby accept that I am entitled to issue a declaration in deviation from the above in respect of individual transaction orders. Being
aware of my liability under criminal law, I hereby declare that the above details are true and correct. I hereby accept that I am obliged to
inform the Bank of any changes in the details supplied as part of the identification procedure within five business days of such changes
coming to my attention.
*If you reside abroad, you have to complete the declaration of customer residing abroad
Declaration of customer residing abroad.
I declare that pursuant to the following I am not a senior public figure. (Please mark with an X.)
I declare that pursuant to the following I am a senior public figure (Please enter the code of the appropriate category below):
1a) Head of state, heads of government, ministers and deputy or assistant minister
1b) Member of Parliament
1c) Member of the Supreme Court, of Constitutional Court or of other high level judicial bodies whose decisions are not subject to further appeal
1d) the head of the court of auditors, member of the courts of auditors, or member of the ultimate decision making organ of the central bank
1e) Ambassador, agent in charge and professional senior officers of the armed forces of general ranks and function
1f) Member of the management, the board or the supervisory body in undertaking with majority holding by the state
1g) executive officers of international organizations
1h) Mayor of the capital city
1i) Trade union leader
1j) Head of national civil organization
2) close relative of the person mentioned in Section 1), that is, a close relative as defined in Section 685, paragraph b) of the Civil Code
(spouse, direct-line relative, adopted, step or foster child, adoptive, step or foster parent, brother/sister, cohabitee, spouse of direct-line
relative, engaged to person mentioned in Section 1), direct-line relative, brother/sister of spouse, spouse of brother/sister)
3a) any natural person who is the actual owner of a legal entity or unincorporated association jointly with a person mentioned in Section
1) or is engaged in a close business relationship with a person mentioned in Section 1)
3b) any natural person who is the single-entity owner of a legal entity or unincorporated organization which was established for the benefit
of a person mentioned in Section 1)
I, the undersigned, hereby consent to the disclosure by Citibank Europe plc. Hungarian Branch Office of the data stated
in the present Application Form to the associated businesses determined in the Accounting Act, in harmony with the
provisions of the Act on the Prevention of Money Laundering, for the purposes of customer vetting serving to prevent
money laundering.
I have acknowledged the information overleaf concerning the management of personal data by the Bank and its
Partners and hereby consent thereto. Yes
Please remember to sign here!
Supplementary Cardholder’s signature:
Main Cardholder’s signature:
Completed by banker/credit mediator!
Image on identification document is identical to the applicant
Signature on identification document is identical to the one on the Application Form.
The undersigned, banker’s/credit intermediary’s name (company name) and code:
and intermediary’s mailing address (head office):
as the employee / contracted intermediary of Citibank Europe plc. Hungarian Branch Office (Szabadság tér 7., Budapest
H-1051, Cg. 01-17-000560; hereinafter: Citibank), legal representative of Citibank Europe plc. (1 North Wall Quay, Dublin 1.,
Ireland) by signing this statement I declare under penalty of perjury that I identified the person submitting this credit card
application in accordance with the provisions of Act CXXXVI of 2007 on the Prevention and Combating of Money Laundering
and Terrorist Financing, the requirements of the General Business Conditions of Consumer Banking of Citibank and the Anti-
Money Laundering policies of Citibank. I also declare that the personal data shown on this application form are fully identical
to the data stated in the personal identification document presented by the applicant to me.
Signature of banker/intermediary:
The credit intermediary acts on behalf of Citibank Europe plc. Hungarian Branch Office.
The present application form consists of two sheets and carries a duplicate copy.
Date: (place), day month year
Page 1/3
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