Security Bank Credit Card Application Form

JUNE 2013
Please attach a photocopy of your supplementary applicant’s NRIC and
submit this form to:
Cards Telemarketing Department,
Level 14, Menara Citibank,
165, Jalan Ampang, 50450 Kuala Lumpur
Fax: 03-2383 9981
Tel No: 1300-13-5555
Terms and Conditions
The use of Citibank Credit Cards (“Card”) is governed by the Citibank Card Terms and
Conditions (which will be provided to me/us upon successful application) and the relevant
terms and conditions for specific Card-type, whichever is applicable, and is binding on the
Principal Cardmember(s) and the Supplementary Cardmember(s). (2) The Principal
Cardmember shall be responsible for all liabilities and obligations of the Principal
Cardmember as well as the Supplementary Cardmember(s). The Principal Cardmember is
jointly and severally liable to us for all amounts and charges due and owing to us from the
use by the Supplementary Cardmember(s) of his/her own Supplementary Card(s). (3) Any
Card(s) issued to me/us, including Supplementary Card(s) must not be used by me/us for
any unlawful activity or purpose (including without limitation online gambling), whether in
whole or part. (4) For principal card applications: I understand that if I am submitting this
application for more than one or multiple Citibank credit cards, I may be participating in
more than one Citibank credit card promotion in which gifts are given for successfully
approved applications. In such event, I hereby CONFIRM that I am the only one entitled to
receive the gift from only ONE of such promotions, regardless of the number of Citibank
credit cards that are successfully approved. For this purpose, and subject to Citibank’s
approval of my applications, my preference of the gift is as indicated on page 1.
By signing below, I confirm that (1) I have read and agree to abide by the provisions
contained in General Declaration for Citibank Credit Card and (2) My minimum income is
RM24,000 per annum or more. (3) For CitiBusiness Card application, my business sales
turnover is RM120,000 per annum or more (N/A if Business Platinum card applicant is
salaried). (4) My signature below constitutes a request for Citibank VISA credit card if I
already have a Citibank MasterCard and vice versa, if applicable. (5) My signature
constitutes a request for Gold/Classic Card if I do not qualify for Platinum/Gold Card. (6) The
Principal and Supplementary Cardmember(s) will be jointly and severally liable to the Bank
for all amounts and charges due and owing however arising from the use by the
Supplementary Cardmember(s) of his own Supplementary Card(s)”. (7) The Bank may allow
the Principal Cardmember(s) to exceed the credit limit/total credit limit and/or the
Supplementary Cardmember(s) to exceed the Supplementary Card(s) limit (if a separate
credit limit is assigned) at the Bank’s sole discretion. (8) The Principal Cardmember(s) and
the Supplementary Cardmember(s) will be bound by the Citibank Card Terms and
Conditions. (9) I have received, read and understood the contents of the Citibank Credit Card
Product Disclosure Sheet.
Citibank’s Privacy Notice
Keeping personal data of individuals secure is a top priority for all of us at Citibank. Please
visit us at to view our Notice and Choice Principle
Statement where we seek to outline how we intend to deliver all the rights and protections
that you are entitled to in respect of your personal data.
Date of application (Mandatory) :
Supplementary card
Applicant :
Applicant’s signature :
yyyydd mm
Agent Code Card Source Code
Form Filled Up By
Staff Applicant
(Sign in black ink only)
Jika anda ingin memasuki kontrak dalam Bahasa Malaysia, sila minta borang tersebut daripada kami. Jika anda menandatangani Borang Pemohonan ini dalam Bahasa Inggeris, anda dianggap telah
memilih dan memahami Bahasa Inggeris sebagai bahasa utama untuk kontrak ini.
Citibank Credit Card Number :
Name of Principal Card :
Full name as in NRIC or passport (underline surname) : Mr Mrs Ms
Full name as in NRIC or passport (underline surname) :
Name to appear on card (max. 19 letters) :
Date of birth : Nationality :
New NRIC no. or passport no. : Old NRIC no. :
Relationship to principal cardmember :
Residential Address. The supplementary card will be sent to the principal
cardmember’s preferred address :
Home tel no. :
Handphone no. :
State : Postcode :
YES, I wish to assign monthly spend limit of
Reminder: The total combined spend cannot exceed the principal cardmember
current approved credit line. CitiBusiness VISA Requirement — For employees
only: minimum income of RM24,000 per annum and minimum age of 21.
Mr Mrs Ms
By signing below, I hereby (1) authorise Citibank Berhad (“the Bank”) to
disclose my personal data, such as my name, address(es), contact numbers,
e-mail address(es) and information pertaining to this application to TEN
Lifestyle Management Ltd (“TEN”) for purposes of providing Citi Prestige
Global Concierge services to me, (2) understand that any personal data
provided by the Bank to TEN shall also be subject to the TEN’s privacy policy
of which details can be located at and to
the full extent permitted by law, the Bank shall not be liable for any
unauthorised disclosure of personal data or breach of confidentiality, and (3)
agree to indemnify and hold the Bank harmless against any liability to the full
extent permitted by law arising from the disclosure of my personal data.
Date of application (Mandatory) :
yyyydd mm
CitiBusiness VISA: For employees only with minimum income of RM24,000
per annum and minimum age of 21.
yyyydd mm
Residential address :
Applicant’s signature :
(Sign in black ink only)
Citi Prestige MasterCard World Elite
Citi PremierMiles AMEX
Citi PremierMiles VISA Signature
Platinum MasterCard
Platinum VISA
Cash Back Platinum VISA
Choice VISA
Clear MasterCard
Clear VISA
Rewards Platinum VISA
Rewards Platinum MasterCard
Cash Back Platinum MasterCard
Business Platinum VISA
CitiBusiness Gold VISA
AirAsia Gold MasterCard
AirAsia Platinum VISA
Shell Gold VISA
AirAsia MasterCard
Giant VISA
AirAsia Gold VISA
Choice MasterCard
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