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YOUR CHOICE OF CARD:
VISA OR
MASTERCARD
BANKING RELATIONSHIP WITH CITIBANK (IF ANY)
CITIBANK ACCOUNT NO(S).
NAME & CONTACT NO. OF CITIBANK RELATIONSHIP OFFICER
OTHER BANKER
OTHER BANKER’S ACCOUNT NO.
BANK REFERENCE
Co. Reg. No: 200309485K
IMPORTANT: Before completing this application, please read the following carefully:
You may apply for Citibank Purchasing card(s) to be issued to your employees/officers whom you nominate as cardholders in the nomination form(s) (“proposed cardholders”)
and be liable for all charges. Please complete this application form in full and a Citibank Purchasing card nomination form for each proposed cardholder. You must submit
certified true copies of your audited financial statements for the last two years.
AUTHORISED SIGNATORY OF COMPANY
DECLARATION
BY SIGNING BELOW, I APPLY TO BE A CORPORATE APPLICANT AND FOR CARD ACCOUNT(S) TO BE
OPENED AND CARD(S) TO BE ISSUED TO EACH OF THE PROPOSED CARDHOLDERS FROM TIME TO
TIME UNTIL THEIR CARD ACCOUNT IS TERMINATED. I AGREE TO BE LIABLE FOR ALL CHARGES AND
OTHER LIABILITIES INCURRED OR OTHERWISE PAYABLE BY THE PROPOSED CARDHOLDERS AND I
AGREE TO BE BOUND BY THE CITIBANK PURCHASING CARD AGREEMENT AND THE TERMS OF
THE PROPOSAL LETTER PREVIOUSLY ACCEPTED BY YOU UPON ACCEPTANCE OF MY APPLICATION
(WHICH MAY BE COMMUNICATED TO ME OR THE PROPOSED CARDHOLDER(S). I WARRANT THAT
THE INFORMATION FURNISHED IN THIS APPLICATION FORM IN ANY DOCUMENTS OR ATTACHMENTS
GIVEN TO YOU IN CONNECTION WITH THIS APPLICATION BY ME OR ANY OF THE PROPOSED
CARDHOLDERS IS TRUE AND ACCURATE. I AUTHORISE ALL PERSONS/ENTITIES AS YOU MAY DEEM
APPROPRIATE TO REQUEST FOR ANY INFORMATION ( CONFIDENTIAL OR OTHERWISE) RELATING TO
ME IN ANY WAY, TO RELEASE THE SAME TO YOU WITHOUT REFERENCE TO ME. I CONSENT TO YOUR
DISCLOSURE TO ANY THIRD PARTY AS YOU DEEM FIT AT YOUR ABSOLUTE DISCRETION ANY
INFORMATION RELATING TO ME IN ANY WAY. I AUTHORISE YOU TO EMBOSS NAME(S) A