Fillable AMEX KYC Form V11 27 Feb2018

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AMEX KYC Form V11 27 Feb2018

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AMEX (Middle East) B.S.C. (c), P.O. Box 5990, Manama, Kingdom of Bahrain، email: kyc@americanexpress.com.bh, www.americanexpress.com.bh
Dear Cardmember,
At American Express, we are committed to ensuring that our records
are up to date with your most recent identification and contact
details along with the supporting documents. In accordance with
regulatory requirements, we are required to request our Cardmembers
to verify and/or update this information every few years.
In view of the above, we kindly request you to complete the
Cardmember Information Update Form (‘the Form’) and submit
photocopies of the below set of documents:
• The first page of your current passport
• National ID (e.g. CPR, Civil ID, Emirates ID etc.) or Residence Permit
• An electricity bill or other utility bill, Govt. issued ID or page of
tenancy agreement containing residential address (only required
for Personal Cardmembers)
• One ID (National ID or first page of the current passport) for each
Supplementary Cardmember, as applicable
While completing the Form, please insert the reference number shared
with you via letter, email and/or SMS, against the field ‘Reference
Number’. Alternatively, you can call the number on the back of your
Card and request for your reference number.
You can submit your signed Form along with the supporting
documents to us through any of the following options:
• Dropping off your Form and the documents to your nearest
AMEX (Middle East) B.S.C. (c) local office
• Emailing scanned copies of your Form and documents to us at
kyc@americanexpress.com.bh
•
Posting your Form and documents to AMEX (Middle East) B.S.C. (c),
P.O. Box 5990, Manama, Kingdom of Bahrain
Should you have any inquiries, please call the Customer Service
number mentioned on the back of your Card and one of our
Customer Service Representatives will be happy to assist you.
On behalf of American Express, we thank you for your cooperation
and continued loyalty.
Yours faithfully,
Julia De Souza
Vice President – Operations and Servicing
Middle East & North Africa
Member Since 1999
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kyc@americanexpress.com.bh
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1999
Cardmember InformatIon Update form
Dear Cardmember,
Thank you for taking the time to complete the Cardmember Information Updated Form. We request you to carefully read the
instructions, fill in the below details (in English) and sign on the Declaration Statement to indicate your acceptance.
AEME/KYC/NOV2017
1. Important InstrUCtIons
The information you provide in this form will be used to verify and update the details listed on your American Express® Card Account issued by AMEX (Middle East) B.S.C. (c).
This information may be used for further verification and authentication before it is updated against your previous available details with us. If updated after validation, this
information will become effective within one month from the date of receipt.
2. aboUt YoUrself
Reference Number
[this number/code will be provided to you via email/letter upfront. Alternatively, you may call the
Customer Service number (mentioned on the back of your Card) to obtain the same].
List of products (Select your Card (s))
The Centurion® Card
The Platinum Card®
The American Express® Platinum Credit Card
The American Express® Gold Card
The American Express® Gold Credit Card
The American Express® Card
The Dubai Duty Free American Express® Card
Blue from American Express
The American Express® Corporate Card
(Tick Here) I certify that the following information stated in this form will apply to all of the Cards selected above.
Title Mr
Mrs
Miss
Ms
Other
Full Name
Date of Birth
D D M M Y Y Y Y
Nationality
Passport No.*
ID No.* (e.g. CPR, Civil ID, Emirates ID, etc. or Residence Permit Number (Iqama))
*Please attach copy of your passport and ID. If you are a GCC national, please provide your respective GCC national ID. For other nationalities, please provide national ID of the
country you are residing in or residence permit (Iqama) in case you do not hold a national ID.
3. ContaCt detaIls (CUrrent)
Residential
Address*
City Country
*Please attach an electricity bill or other utility bill/Govt. issued ID containing residential address/page of tenancy agreement showing residential address (only required for Personal
Cardmembers)
Tick here if Billing Address is the same as Residential Address, otherwise provide the billing address below
Billing Address
City Country
Home Tel. No. (with area code)
Mobile Tel. No. (with area code)
Other Tel. No. (with area code)
Email (1)
Email (2)
I am holding an American Express Corporate Card and wish to have separate Billing Address/Contact Details for it (please fill-in the below):
Billing Address
City Country
Mobile Tel. No. (with area code)
Other Tel. No. (with area code)
Email
4. emploYment detaIls
Current Employment Status
Employed
Self-Employed
Please specify nature of business
Retired
Unemployed
Company Name
Company Address
Job Title
Office Tel. No. (with area code)
Source of Funds* (select all that apply) Salary Income Business/Profession Income Other Income (please specify)
*only required for Personal Cardmembers.
6. deClaratIon statement
I hereby declare that the information provided by me in this form is true and correct and I am aware that it will be used to verify and update the applicable details listed on all the
American Express® Card number(s) issued under my name by AMEX (Middle East) B.S.C. (c) (“AEME”). I further declare that I shall promptly advise AEME if there are any changes to
this information. I am aware that the above information is critical to maintain my Cardmembership with AEME. I authorise any correspondences originating from AEME, including the
Statement of Account and other mailed items, couriered parcels, emails, and outbound phone calls, to be carried out using the details I have specified above. I am fully aware of the
sensitivity of the above information and I acknowledge that should there be any discrepancies between the details I have specified above and any details provided in conjunction
with a transaction (i.e. following an online transaction, mail order, and/or any other transaction in which Cardmembership contact details must be verified), the transaction may be
declined as erroneous unless I rectify them with the details I have specified above. I am aware that the above information is critical to maintain my Card Account and/or contractual
obligation with AMEX (Middle East) B.S.C (c) and failure to timely update the information may result in suspension and/or termination of my Card Account.
Basic cardmemBer signature
DATE
5. sUpplementarY Cardmember detaIls (onlY If applICable)
1. Title Mr
Mrs
Miss
Ms
Other
Full Name
Date of Birth
D D M M Y Y Y Y
Nationality
ID No. (e.g. CPR, Civil ID, Emirates ID, etc. or Residence Permit Number (Iqama)) or Passport No.*
Mobile/Tel. No. (with area code)
Email
2. Title Mr
Mrs
Miss
Ms
Other
Full Name
Date of Birth
D D M M Y Y Y Y
Nationality
ID No. (e.g. CPR, Civil ID, Emirates ID, etc. or Residence Permit Number (Iqama)) or Passport No.*
Mobile/Tel. No. (with area code)
Email
3. Title Mr
Mrs
Miss
Ms
Other
Full Name
Date of Birth
D D M M Y Y Y Y
Nationality
ID No. (e.g. CPR, Civil ID, Emirates ID, etc. or Residence Permit Number (Iqama)) or Passport No.*
Mobile/Tel. No. (with area code)
Email
4. Title Mr
Mrs
Miss
Ms
Other
Full Name
Date of Birth
D D M M Y Y Y Y
Nationality
ID No. (e.g. CPR, Civil ID, Emirates ID, etc. or Residence Permit Number (Iqama)) or Passport No.*
Mobile/Tel. No. (with area code)
Email
5. Title Mr
Mrs
Miss
Ms
Other
Full Name
Date of Birth
D D M M Y Y Y Y
Nationality
ID No. (e.g. CPR, Civil ID, Emirates ID, etc. or Residence Permit Number (Iqama)) or Passport No.*
Mobile/Tel. No. (with area code)
Email
*Please attach copy of passport or ID. If you are a GCC national, please provide your respective GCC national ID. For other nationalities, please provide national ID of the country you
are residing in or residence permit (Iqama) in case you do not hold a national ID.
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AMEX KYC Form V11 27 Feb2018

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Completed 16 July 2020

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