Citibank Malaysia

Please complete application form in English only.

Mail or Fax the documents to:

Mail it to:
Citibank Berhad (297089-M),
Internet Sales Unit
Level 35, Menara Citibank
165, Jalan Ampang,
50450 K.L

or Fax to: 03-2383 9090

Questions? Call us at 03-2383 4088
(Mon – Fri, 9am – 6pm).

CITIBANK VISA / MASTERCARD APPLICATION FORM

For bank's use.
PV    B03    B06    B09    B33    B35    B44    B55    B83    B88    Incomp
       IN               ID                PR               IT      PP
       RJ ____________________ D ____________________

2 / 9
<35
7

2 / 9
>35
4 / 5

S 680 G 780 P 880 (For Cash Back Card only)

S 260 G 250 (For Celcom Card only)

Please type or print throughout. Complete the form in full. Please tick both cards if you are applying for more than one card. *Delete whichever not applicable. I wish to apply for

Choice VISA	Choice MasterCard	Cash Back VISA
Silver VISA	Silver MasterCard	Platinum VISA
Gold VISA	Gold MasterCard	Platinum MasterCard
Clear VISA	Clear MasterCard	Celcom VISA

For Choice application
Enrol FlexiPayment Plan?	Yes (Minimum RM 500 / 12 months) No

For Celcom application (post-paid user only)
Celcom Account Number	(8 digits)
Payment mode	One Bill* SMS* *5% rebate on total phone bill
X ______________________________________________ Signature
(Call 1111 from your mobile to check A/C number)

1	TELL US ABOUT YOURSELF

Full name as in *NRIC or passport
(underline surname):

Mr Mrs Ms

Sex:

Male Female

Name to appear on card
(not more than 19 letters):

Date of birth (Mth / Day / Yr):

/ /

Nationality:

New NRIC no.:

Old NRIC no.:

Home address:

Home tel.:		-
Handphone no.:		-

Postcode:

E-mail:

Permanent home address:

Postcode:

Marital status:

Send bill to:

Send card to:

Residence is:

Since: years

Mother's name
(This security feature is required for your protection):

Academic qualification:

2	SPOUSE'S DETAILS (info is required if married)

Name of spouse (underline surname):

Mr Mrs

Name of employer or firm & dept., if any:

Office tel.:

Ext.:

3	TELL US ABOUT YOUR EMPLOYMENT OR BUSINESS

Name of *employer or firm:

Office address:

Postcode:

Nature of business:

General line:

Ext.:

Office direct tel.:

Position:

*Date joined/years established (if self employed):

If own business, business registration no.:

Name of previous employer
(if less than 2 years in present employment):

Office tel.:

Position:

Years there:

4	YOUR INCOME

Annual salary or income:

5	OTHER CREDIT OR CHARGE CARDS HELD

Bank	Card No.	Member Since	Amount to be transferred


Total amount to be transferred

Balance Transfer Application:
I would like to transfer the following outstanding bill(s)

This transfer is based solely on my instructions and has no implication on my relationship with any card issuer. You may approve or reject my request at your sole discretion. I understand this invitation is not transferable. I agree to abide by the terms and conditions of Citibank Berhad's Balance Transfer/Ready Cash Fund Transfer Program and Citibank Card Agreement.

Principal Cardholder's Signature:

______________________________________________

Terms and Conditions apply.

Important Notes
• Minimum acceptance transfer for each one of other banks' credit/charge card, is RM1,000
• Transfer up to 100% of credit limit
• Enclose latest bank statements or payment stubs of other banks' credit/charge cards
• Application is for one-time transfer only
• Subject to final approval by Citibank
• The prevailing promotional interest rate shall apply
• Promotional rate for limited time only

For office use only:
Campaign Code:

6	EMERGENCY CONTACT PERSON (Relative not staying with you)

Name:

Relationship

Home tel. no.

Office tel. no.

Handphone no.

Home address

Postcode:

7	YOUR BANKERS

Bank Name	Branch	Type of account

8	SUPPLEMENTARY CARD

Full name as in *NRIC or passport
(underline surname):

Mr Mrs Ms

Sex:

Male Female

Name to appear on card
(not more than 19 letters):

Mother's name:

Date of birth (Mth / Day / Yr):

/ /

Nationality:

New NRIC no.:

Old NRIC no.:

Relationship to principal cardmember:

Home address
(Even if same as principal cardmember):

Home tel. no.:		-

Postcode:

Name and address of employer:

Office tel. no.:		-
Ext:

Postcode:

Occupation:

	Yes, I would like to nominate a credit line for this supplementary applicant of RM
	No, I do not wish to nominate. This supplementary applicant will share my current credit line
Reminder: In either of the above instances, the total combined credit lines cannot exceed the principal cardmember's current approved credit line.

For Supplementary Applicant
Senior public office (eg. Ministerial or diplomatic positions)

	Yes, I/my immediate family members
	currently hold have held are actively seeking are being considered for
Senior public office Position held: Period hold from: (dd/mm/yy) to (dd/mm/yy)

	No, I/my immediate family members do not hold, have never held, are not actively seeking and are not being considered for senior public office.

9	YOUR OPTIONAL CITIBANK CREDIT SHIELD PLUS

	YES! I wish to protect my Outstanding Balance with Citibank Credit Shield Plus and be entitled to 30 days' free cover. I declare that I am under 60 years of age and in good health and have not been suffering from any illness, disease, bodily injury and/or physical impairment/defect and have not received or expect to receive treatment with regards to any illness, accident, AIDS or HIV related conditions. A Certificate of Insurance with terms and conditions will be sent to me upon my enrolment.
	NO! I do not wish to be covered under this exclusive protection plan.

Pursuant to section 149(4) of the Insurance Act 1996, you are to disclose in this application form fully and faithfully all facts which you know or ought to know. Otherwise the certificate of insurance issued under the policy may be null and void. This Insurance plan is limited to principal cardholders below the age of 60 years.
Citibank Credit Shield Plus is underwritten by ING Insurance Bhd
These insurance products are obligations only of the insurance company. They are not bank deposits or obligations of or guaranteed by Citibank Berhad, Citibank NA, Citigroup Inc., or any of its affiliates or subsidiaries. This document does not constitute the making of any offer or invitation to subscribe for insurance products nor does it amount to solicitation by Citibank Berhad, Citibank NA, Citigroup Inc. or any of its affiliates or subsidiaries for applications of insurance products by anyone in any jurisdiction in which the making of such offer or invitation to subscribe or the solicitation thereof is not authorised or to any person to whom it is unlawful to make such an offer, invitation or solicitation. This document also does not constitute the distribution of any information by anyone in any jurisdiction in which such distribution is not authorised or to any person to whom it is unlawful to distribute such a document.

10	DECLARATION

Senior public office (eg. Ministerial or diplomatic positions)
	Yes, I/my immediate family members.
	currently hold have held are actively seeking are being considered for
Senior public office Position held: Period hold from: (dd/mm/yy) to (dd/mm/yy)

	No, I/my immediate family members do not hold, have never held, are not actively seeking and are not being considered for senior public office.

I/We certify that all the above information is true and valid. I/We hereby authorize the bank to verify from whatever sources the bank may consider appropriate including Inland Revenue. I/We acknowledge that the card may only be used subject to the terms and conditions of the Citibank Card Agreement. I / We agree to be bound by the terms and conditions which accompany the card(s). Upon approval, I/we agree to pay prevailing annual fees. I/We agree to accept full liability for all my/our card account(s) with you notwithstanding any credit limits imposed on the use of my/our Cards. The principal cardholder shall additionally be liable for all amounts and charges incurred in respect of the use of any supplementary card. I/We understand that the bank reserves the absolute right to reject or approve my/our application(s) as the bank deems fit without assigning any reasons thereof. The Bank may at its discretion to approve only 1 credit card or a lower card type as it deems fit. I/We understand my/our signature above constitute my/our request for such credit card account. I/We confirm that my/our borrowings (other than for financing immovable property in Malaysia) from all sources within Malaysia do not exceed in aggregate RM200,000. (Applicable to non-Malaysians only). I/We understand that the card, when issued, shall remain the property of Citibank Berhad and shall be subject to cancellation without notice. By signing and/or using the card, I/we agree to be bound by the terms and conditions specified in the Citibank Card Agreement and all future amendments thereto.

I/We hereby give the Bank an irrevocable and unconditional consent to disclose any information pertaining to this credit card application and/or all advances, credit or banking facilities granted by the Bank to me/us and/or any banking facilities or other account otherwise which I/we may have with the Bank and without prejudice to the foregoing any information relating to me/us to such extent as the Bank may at the Bank's sole and absolute discretion deem necessary ("the Information") for any purpose whatsoever to the Bank's branches, Citigroup Inc. subsidiaries and affiliates, Bank Negara Malaysia ("BNM"), the Central Credit Unit, the Central Credit Reference Information System, the Biro Maklumat Cek and such other authority or body established by BNM or any other authority having jurisdiction over the Bank, permitted assignees and other persons authorised by the Bank. I/We hereby confirm that no further permission or consent from the undersigned is necessary or required in relation thereto and this shall constitute the consent required pursuant to Section 99(1)(a) of the Banking and Financial Institutions Act 1989 and any other contractual consent for such disclosures.

I/We hereby agree that any disclosure by the Bank of the Information will not render the Bank liable to me/us for any claim, loss, damage (including direct or indirect damages or loss of profits or savings) or liability howsoever arising whether in contract, negligence, or any other basis arising from or in relation to:-
(i) the release or disclosure of the Information by the Bank; and/or
(ii) the Information being incorrect, erroneous or misstated; and/or
(iii) reliance of the Information, whether caused by the Bank or other third party's omission, misstatement, negligence or default or by technical, hardware or software failures of any kind, interruption, error, omission, viruses, delay in updating or notifying any changes in the Information or otherwise howsoever.

I/We certify that all information furnished in support of this application is true and valid.

NOTE: In the event of any conflict or discrepancy between the English text and any translation thereof, the English text shall prevail.

Signature of Principal Card applicant:
X

______________________________________________ (Sign in black ink only)
Date:

Signature of Supplementary Card applicant:
XX

______________________________________________(Sign in black ink only)
Date:

For bank's use:
AGENT CODE
SOURCE CODE
GIFT SET
BT SOURCE CODE

MUSTAHAK

ANDA PERLU MENGGUNAKAN KAD KREDIT CITIBANK CARU UNTUK MENIKMATI TAWARAN PENGECUALIAN YURAN TAHUNAN

YURAN DAN CAJ

Kad Kredit Ready Cash

Caj	Amaun
Bayaran yuran keahlian tahunan	RM120 setiap kad
Yuran penyertaan	Tiada
Caj Kewangan: • Pembelian melalui penggunaan kad kredit • Pembayaran melalui penggunaan cek • Pengeluaran tunai menggunakan kad kredit	1.25% sebulan atau15% setahun ke atas amaun tertunggak yang dikira berdasarkan kadar harian 1.25% sebulan atau15% setahun ke atas jumlah amaun yang tertera pada cek dikira berdasarkan kadar harian 1.25% sebulan atau 15% setahun ke atas jumlah yang dikeluarkan berdasarkan kadar harian
Perolehan kembali / caj salinan semula: • Draf Jualan • Penyata akaun • Cek Citibank RC	• RM20 bagi setiap salinan mikro filem • RM5 bagi setiap penyata • RM10 bagi setiap helai
Caj perkhidmatan untuk Arahan Pemberhentian Bayaran: Caj perkhidmatan sekiranya berlaku Pemulangan Cek kerana nilai cek yang dikemukakan melebihi nilai kredit akaun Caj perkhidmatan sekiranya berlaku Pemulangan Cek kerana arahan pemberhentian pembayaran telah diterima dan nilai cek yang diberhentikan pembayarannya itu telah melebihi nilai kredit akaun Caj perkhidmatan sekiranya berlaku Pemulangan Cek kerana sebab-sebab lain	RM10 bagi setiap arahan RM100 bagi setiap cek RM100 bagi setiap cek RM10 bagi setiap cek

Kad-kad lain

a) Yuran tahunan:
	VISA (RM)		MasterCard (RM)
Jenis Kad	Prinsipal	K. Tambahan	Prinsipal	K. Tambahan
Classic/Standard	70	45	70	45
Clear	90	60	90	60
Cash Back	90	60	–	–
Gold	195	100	195	100
Platinum	600	K. tambahan pertama percuma. Seterusnya RM150.	600	K. tambahan pertama percuma. Seterusnya RM150.
Choice	TIADA
b) Yuran Perkhidmatan Choice		RM5 setiap bulan. Dikecualikan jika 2 atau lebih transaksi (pembelian runcit atau pendahuluan wang tunai) dalam bulan sebelumnya. Kad tambahan percuma
c) Caj Kewangan i) Pembelian ii) Wang tunai pendahuluan iii) Pindah Baki		Caj adalah seperti berikut : 18% setahun daripada jumlah baki tertunggak berdasarkan pengiraan harian Sehingga 18%* setahun daripada jumlah wang tunai pendahuluan berdasarkan pengiraan harian Sehingga 18%* setahun daripada jumlah baki yang dipindahkan berdasarkan pengiraan harian
d) Yuran wang tunai pendahuluan		Yuran wang tunai pendahuluan adalah sehingga 5%* daripada jumlah wang tunai pendahuluan atau minimum sebanyak RM20, atau yang mana lebih tinggi. Ia akan dikenakan bagi setiap urus niaga wang tunai pendahuluan
e) Bayaran balik bulanan		5% daripada baki tertunggak atau minimum sebanyak RM50.
f) Caj bayaran lewat		Caj bayaran lewat yang dikenakan ialah sebanyak 1% daripada jumlah minimum bayaran balik yang perlu dijelaskan atau minimum sebanyak RM5, atau yang mana lebih tinggi
g) Tempoh tanpa faedah		20 hari daripada tarikh penyata bil bulanan dan hanya sah untuk urus niaga pembelian sahaja
h) Pertukaran untuk urus niaga luar negara		Kadar pertukaran adalah ditentukan oleh VISA atau MasterCard dan fi International Service Assessment/Multi Currency Conversion sebanyak 1% dicampurkan dengan fi pengurusan sebanyak 1%

* Yuran dan caj ini mungkin ditawarkan pada kadar promosi yang lebih rendah untuk tempoh tertentu.

TERMS AND CONDITIONS FOR BALANCE TRANSFER

Holders of any Citibank Berhad Principal Credit Card (“Cardholder”) invited by the Bank may apply to transfer outstanding balance (including principal, accrued interest, finance and other charges) (“Outstanding Balance”) as shown in the latest corresponding account statement(s) from Principal Card Accounts of credit cards held in their name issued by Malaysian Credit Card Financial Institutions billed in Ringgit Malaysia except Citibank to any Citibank Principal credit card account held by the Cardholder (“Card Account”) whereby the Bank may pay the outstanding balance or a portion thereof the balance by debiting the Cardholder's Card Account.
The above payments utilizing the Cardholder's Citibank credit card shall be known as the Balance Transfer Program (“Program”).
The minimum acceptance transfer is subject to the Bank's sole discretion.
Balance Transfer will normally be effected within 14 days from the Bank's receipt of the relevant documents from the Cardholder. However, the Bank may defer or even refuse the process of effecting balance transfer and not be liable to the Cardholder for instance, if the outstanding balance to be transferred exceeds the Cardholder's credit limit, if the outstanding balance does not meet the minimum prescribed transfer amount, if the Cardholder's Citibank Card Account has a positive balance or insufficient balance, circumstances beyond the Bank's control or security reasons demand such. The Bank will notify the Cardholder within 14 days of the outcome of the Cardholder's application for balance transfer. Where the Cardholder's application is successful, payment to card accounts with the licensed institution will be made in the manner provided herein.
Unless waived by the Bank in its sole discretion, the Cardholder must, where applicable and as the Bank may require, submit the latest bank statements and such further or other documents that the Bank may deem necessary.
Upon the approval of the Bank of the Cardholder's application and upon the Cardholder's Citibank credit card being duly debited with the Outstanding Balance, the Outstanding Balance or any part thereof will be subject to the Special Interest Rate for the whole of the Special Interest Rate Term and thereafter, finance charges at the usual rate of 18% p.a. will be chargeable. However, if at any time the Cardholder's Card Account becomes overdue or delinquent, the Bank may in its absolute discretion charge on the Outstanding Balance or a portion thereof finance charges at the usual rate of 18% p.a. notwithstanding that it is still during the Special Interest Rate Term. Further in addition thereto and not in derogation thereof exercise its rights under the Card Agreement in respect of the whole outstanding balance or a portion thereof in accordance with the provisions of the Card Agreement.
The Special Interest Rate refers to such rate the Bank may specify from time to time and publish at time the Program is applied for. For the avoidance of doubt, the Special Interest Rate only applies to the transferred outstanding balance or any part thereof during the Special Interest Rate Term. The Special Interest Rate Term refers to such term the Bank may specify from time to time and publish or such time the Program is applied for. For the avoidance of doubt, the Special Interest Rate Term only applies to the transferred outstanding balance or any part thereof.
Once a specified amount of outstanding balance to be transferred has been approved, a corresponding amount of the Cardholder's existing credit availability will be reserved for this purpose and shall not be available to the Cardholder until settlement of the said outstanding balance. On the date of posting (“Date of Posting”) this specified amount will then be utilized and finance charges will commence thereon.
Notwithstanding the terms and conditions herein, the Cardholder shall continue and remain liable to the other licensed institution for the facilities enjoyed by the Cardholder in accordance with the terms governing the same.
The Bank in implementing the Program shall not be liable to the Cardholder for any interest or any other finance charges incurred by the Cardholder to the other licensed institution caused by a delay or failure on the part of the Bank in paying the Outstanding Balance, notwithstanding the Bank's approval of the Cardholder's application, to the other licensed institution concerned.
The Bank has the absolute right to approve and transfer the whole or part of the amount of the outstanding balance applied for without prior notification to the Cardholder. The Bank is not obliged to assign any reason to the Cardholders in respect of the exercise of its discretion and neither is the Cardholders' consent necessary.
The Cardholder has read and understood the details and the Terms and Conditions of the Balance Transfer Program (“Program”) herein specified. These Terms and Conditions are in addition to the Credit Card Cardholder Agreement which regulates the provision of credit card facilities by the Bank. In the event of inconsistency between these Terms and Conditions and the said Agreement these Terms and Conditions shall prevail in so far as they apply to the Program.
Expressions defined in the Terms and Conditions shall, unless context requires otherwise, have the same meanings as those ascribed to them in the Credit Card Cardholder Agreement referred to in Clause 12 above.
Balance Transfer transaction is treated as Cash Advance where interest is calculated daily from the date of approval. Payments made by the Cardmember to the Bank whether by direct debit to the Cardmember's other accounts or otherwise will be applied to the following order: firstly, finance charges, fees, including legal fees (on a full indemnity basis) or other charges and lastly, the outstanding principal amount of the transaction from the lowest finance charge rates to highest finance charge rates; or in any other order as the Bank consider appropriate without prior reference to the Cardmember.
The bank reserves the right to alter these Terms and Conditions from time to time without prior notice and such amendments shall be binding and lawful on the Cardholders notwithstanding the fact that the Cardholders may not have written notice of it.
These Terms and Conditions shall be governed by and construed in accordance with the laws of Malaysia.
In the event where there is a discrepancy between the English & Bahasa Malaysia version, the English version shall prevail.
The outstanding balance to be transferred is subject to the Cardholder's Citibank Card Account available credit limit at the time the application for balance transfer is being processed. If the Cardholder has applied to effect a balance transfer in excess of the Cardholder's credit limit, the Bank may at its absolute discretion approve the whole or any part of the amount of the balance transfer applied for without prior notification or assigning any reason to the Cardholder or requiring the Cardholder's consent.
The Cardholder cannot fully pay or transfer the outstanding balance to any other bank or financial institution or any Citibank account during the Special Interest Rate Term. If the Cardholder does so, the bank reserves the right to debit outstanding financial charges at 18% p.a., if any, to the Cardholder's Citibank Credit Card Account.
Citibank reserves the right to terminate or suspend this promotion without prior notice.
Promotion is valid for a limited time only.

IMPORTANT: TO ENABLE SPEEDY PROCESSING OF YOUR APPLICATION,
PLEASE REMEMBER TO ENCLOSE:

IF YOU ARE AN INTERNATIONAL CREDIT CARDHOLDER FOR 18 MONTHS OR CHARGE CARDHOLDER FOR 12 MONTHS:

IF YOU ARE NOT AN INTERNATIONAL CREDIT OR CHARGE CARDHOLDER:

This feature applies if your card is not limited to use in Malaysia or Singapore and if you intend to hold only one Citibank credit card (VISA or MasterCard)

Enclose/

•	Photostat copy of your I.C. (both sides) or passport.
•	Photostat copy of your international charge card or credit card (both sides) issued by a bank.
•	Latest 2 months' card charges statements.

Enclose

•	Photostat copy of your I.C. (both sides) or passport.
•	Latest income tax return (Form J).
•	Latest salary slip or letter from employer.
•	Latest 3 months' bank statements.
•	Copies of business registration.
•	Photocopy of your graduation certificate.
•	Photocopy of appointment letter from employer or latest salary slip.
•	Or any other income supporting documents.

PLEASE NOTE: ENCLOSED DOCUMENTS ARE NON-RETURNABLE.