Basic TSB No:
Supp TSB No:
Note: Your application cannot be processed unless sections 1-5 and 9 are fully completed.
TSB GOLD DM 06/08
1. See Balance Transfer Section on Declaration overleaf.
For Office Use Only
Other Credit Details
Issuer of Most Frequently Used Card
(e.g. Bank, not American Express or Store Card)
Current Credit Limit of Most Frequently Used Card $
Current Outstanding on Most Frequently Used Card $
YES, I am over 18 years of age
YES, I have a good credit history*
YES, I earn more than $35,000 p.a.
YES, I have a regular source of income
*American Express reserves the right to decline applicants who do not satisfy credit approval and income criteria.
Mr / Mrs / Ms / Miss
Preferred name on the Card (maximum 20 characters).
Date of Birth
D D / M M / Y Y
Are you an American Express Cardmember?
If you already hold or have held an American Express Card, please give the Account Number.
Tick if you would like to cancel your existing American Express Credit Card and have the balance transferred
to your new Card upon approval. You will also need to transfer any automatic payments (direct debits and
recurring billings) and any Cash Advance facilities to your new account.
Name of friend or relative
not living with you (living in NZ)
Phone No. ( )
For your security and to meet legal requirements, we need to verify the identity of all Cardmembers. To assist in this process we require
your NZ Driver’s Licence Number and/or Car Registration number if held.
NZ Driver’s Licence No.
(Field 5a on your Licence)
Car Registration No.
Note: Your NZ Driver’s Licence No. and Car Registration No. will be verified with the LTNZ for confirmation of identity.
Please note, American Express may need to contact you to gather additional in