I agree with the terms set out in this application form and in the General
Conditions, of which I received a copy, and I declare on my honor that all the
concerning information on this document is correct and complete and
undertake to inform Diners Club as this information changes.
Completed in :
Signature (to be preceded by “read and approved”) :
o Mr o Ms
Mobile Phone Number
o I wish to use the free service ‚ on my mobile phone number.
Date of birth
Place of birth
National register number
Civil status : o Single o Married o Separated o Divorced o Widowed
Number of dependents
You are : o Owner o Lodger o Family home
Bank account number
I am a holder of a : o American Express o Visa o MasterCard o Other
If I have been a Diners Club member before, my cardnumber was
Your mother’s maiden name (for security reasons)
Application form for
a Diners Club card
E PERSONAL DATA
I am : o Employee o Retired o Independent o Self employed o Other :
If you have been employed for less than a year, indicate previous employer :
Send your application form to : Diners Club Benelux, division of
Citibank Belgium SA/NV - Bld Général Jacques 263g - 1050 Brussels.
Only duly completed application forms will be considered.
For more info : +32 (0)2 626 50 24.
IMPORTANT : please enclose a copy of your ID card (front & back) or passport, and a copy of a
latest proof of your income (personal income tax assessment required for the independent
professions). Without these documents we will not be