Account Information Update Your Financial Details A review of your American Express® Cardmember account has indicated that we require some additional/updated information. Please complete this form and return to American Express to ensure the ongoing availability of your Card. Are you: Employed Retired Source of income: Title: First names: Family name: Date of birth: Mr Mrs Miss Other l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l D l D lMlM l Y l Y American Express Card number 3 7 - Job title: Years with employer/ self employed: Business/ employer’s name: Nature of Business: Business/ employer’s address: - l l l l l l l l l l l l l l l l Nationality: Please provide a copy of proof of your identity. Select the type of document and enter the document number: City: Passport Drivers licence ID Card Document number: Please give your permanent home address (including country and postal code) Care of (c/o) business/PO box addresses are not acceptable. l l l l l l l l l l l l l l l l Address: City: Country: Postal code: Home tel number: (inc. country & area code) Mobile tel number: (inc. country & area code) Email address: l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l Country: Postal code: Tel. number: (inc. country & area code) Accountant’s name: (if self-employed) l l l l l l l l l Accountant’s address: l l l l l l l l l l l l l l l l l l l l l l l l l City: Country: Postal code: Accountant’s Tel. number: (inc. country & area code) Providing American Express with your email address will allow us to send you email offers which we believe are suited to your needs, including information on new benefits, products and services. You may request not to receive these offers at any time by updating your email preferences via the privacy statement link on the American Express website. Please note we can accept a maximum of 30 characters for your email address. In the last year, have you or a family member or close associate (including anyone with a close business relationship, eg joint ownership of company, partnership, or anyone benefiting from any company/other entity you own) held the position of: Head of state, minister, deputy or assistant minister? Member of parliament? Member of Supreme Court, of a constitutional court or other high-level judicial body? Member of court of auditors or of the Board of the Central Bank? Ambassador, chargés d'affaire or highranking officer in the armed forces? Member of the administrative, management or supervisory bodies of a state-owned enterprise? Please tick if ‘Yes’ If you answered yes to any of the above, please state: Title of role: Name of the organisation: l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l Country of the organisation: If a close associate, give names and relationship to you: l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l Homemaker GBR£ Trust fund/Inheritance (e.g. private income. Please specify) US$ Amount l l l l l l l l l l l l l l l l l l l l l l l l l years l months l l l l l l l l l l l l l l l l s l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l Please complete if you are self-employed. l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l Investments Savings Other Gross annual income: Student Other (Please specify) Salary Please complete in English using Blue or Black ink and CAPITAL LETTERS. Your Personal Details Self-employed l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l Please Sign Below By signing below, I confirm the information I have given on this form is true and correct. Cardmember please sign here D D M M Y Y X Please send the completed form to: UK Executive Customer Relations Department 333 1 John Street Brighton BN88 1NH Alternatively, fax the documentation to: +44 (0) 1273 624026 IMPORTANT. Please ensure you provide: • Proof of your address (e.g. Utility bill or bank statement dated within the last three months.) • Copy of your passport, drivers licence or identity card. American Express Services Europe Limited, Registered Office: Belgrave House, 76 Buckingham Palace Road, London, SW1W 9AX, United Kingdom, registered in England and Wales with number: 1833139.