FOR ALPA-S / SHA / SIASU AUTHORISATION:
1. Recommend & approve the submission of the herein mentioned Cardmember’s application for the Diners Club Card.
2. Conrm the applicant’s membership / employee status, annual income & position indicated herein and the association
supports the application.
Name of
Authorised
Signatory:_______________________________________
Designation:_____________________________________
_____________________________________________
Authorised Signatory / Stamp / Date
DINERS CLUB AFFINITY CREDIT CARD Application Form
YES! I wish to apply for a: Diners Club Afnity Credit Card
Entrance Fee: $80-WAIVED. Annual Fee: $30 (Basic Card); $15 (Supplementary Card)
*Please check with your Organisation for fee waiver!
Min. Income: Singaporeans/PRs: S$30,000p.a.; Employment Pass Holder: S$80,000p.a.;
Singaporeans/PRs aged 55 & above: S$15,000p.a. Age Criteria: 21 to 65 years old
CONSUMER ADVISORY: If you wish to have a free credit report, you may obtain it within 30 calendar days from the date of approval or rejection
of this application via the credit bureau websites listed below. Alternatively, you may bring the approval or rejection letter and your NRIC to the
credit bureau’s registered ofce to obtain a free credit report.
Credit Bureau (Singapore) Pte Ltd www.creditbureau.com.sg OR DP Credit Bureau Pte Ltd www.dpcreditbureau.sg
My Employment
COMPANY ADDRESS
NAME OF COMPANY
DATE JOINED
POSITION HELDOFFICE TEL
GROSS ANNUAL INCOME
S$
FULL NAME AS IN NRIC (Please underline SURNAME)
LOCAL HOME ADDRESS (Should not be a P.O. Box address)
HANDPHONE (MANDATORY)
Own Mortgaged
Rented
Parent’s / Relatives’
Years of Stay
E-MAIL (MANDATORY if available)
+
PLEASE EMBOSS MY NAME AS FOLLOWS (MAX. 23 SPACES & INCLUDE INITIALS OF FULL NAME)
:
TEL
NAME OF CLOSEST RELATIVE / FRIEND NOT LIVING WITH ME
My Personal Details
HOME PHONE
+
The proposed embossed name may be altered to comply with Diners Club’s card embossing specications.
RESIDENCE
I AM SELF-EMPLOYED
My Spouse
(Married applicant to complete)
SPOUSE’S FULL NAME AS IN IC/PASSPORT (Please underline SURNAME)
GROSS ANNUAL INCOME
S$
POSITION HELD
NAME OF EMPLOYER
DATE OF BIRTH ( Y Y Y Y / M M / D D )
IC / PASSPORT NO.
HANDPHONE (MANDATORY)
My Financial Particulars
I HOLD THE FOLLOWING CREDIT/CHARGE CARDS:
1. A/C NO.
2. A/C NO.
MY BANK BRANCH
TYPE OF A/C A/C NO.
I HAVE NEVER HELD A DINERS CLUB CARD BEFORE
I HAVE HELD A DINERS CLUB CARD BEFORE, MY CARD A/C NO.:
FOR FOREIGNERS: OVERSEAS HOME ADDRESS (Should not be a P.O. Box address)
PLEASE SEND MY BILLING STATEMENT TO:
MY HOME OR
NOTE: Diners Club reserves the right to credit check an applicant wthout reference, and to reject an application without
assigning any reasons therefor. Your signatures in this form and on your Diners Club Card should be identical. You will be
bound by the terms and conditions in this form even if your signatures differ.
AFFINITY ORGANISATION
MEMBERSHIP NO.
No. of
Dependants
GENDERIC / PASSPORT NO.
MARITAL STATUS NATIONALITY
ACADEMIC QUALIFICATIONS
DATE OF BIRTH ( Y Y Y Y /
M M / D D )
RACE
1 yr FOC | 17RW
Apply by 28 Feb 2018
F O R D I N E R S C L U B U S E O N L Y
APP
DATE
By signing below, I/we
1. hereby request Diners Club (Singapore) Pte. Ltd. (DCS) to open a Card Account (Card Account) for me/us and to issue DCS
Credit Card(s) (the Card) (including renewal Card(s)) until the Card Account is terminated. For joint card application, we
agree that the Card Account shall be opened in the name of the rst signatory (termed Basic Card Applicant for administrative
purpose) and the second/other signatory shall be the Supplementary Card applicant.
2. hereby authorise DCS and/or its representatives to contact my/our bankers or any other source to obtain and verify
any information about me/us as DCS may be required to do so by law, and consent to DCS’s use, disclosure, and/or
processing of information relating to me/us and my/our use of the Card(s) for any of these purposes: (a) account opening,
and operations relating to my/our account including closing my/our account; (b) providing services and facilities to me/us
from time to time; (c) administration and/or managing the relationship between DCS and/or my/our account; (d) carrying out
my/our instructions or responding to any enquiries by me/us; (e) the process of approving my/our application, the conduct
of credit and/or identity checks, verication of ongoing credit worthiness; (f) developing new services and/or products; (g)
to provide me/us with marketing, advertising and promotional information, materials and/or documents relating to banking,
investment, credit and/or nancial products and/or services that DCS with business partners (such as co-branders) may
be selling, marketing, offering or promoting, whether such products or services exist now or are created in the future. I/
We understand that I/we have the right to opt out of receiving such marketing information and can do so by writing to
DCS, telephoning DCS or sending an email to DCS at DCS’ address or number on the Website. However, if I/we do not
exercise my/our right to opt out of receiving such marketing information, I/we will be considered to have consented to the
receiving of such marketing information and DCS with business partners (such as co-branders) may continue to provide
such marketing information to me/us; (h) to comply with the disclosure requirements of any regulatory authority or applicable
law; (i) investigating fraud, misconduct, any unlawful action or omission, whether relating to my/our application or any
other matter relating to my/our Account(s), and whether or not there is any suspicion of the aforementioned; (j) carry out
due diligence or other screening activities in accordance with DCS’s legal or regulatory obligations or risk management
procedures designed to combat nancial crime, including “know-your customer”, anti-money laundering, counter-terrorist
nancing or anti-bribery and corruption customer and counterparty due diligence and screening; (k) to update me/us on
DCS’s products and services from time to time; taking out an insurance policy which may provide coverage to me/us and
some members of my/our immediate family; (l) if consented by me/us in the application form, account opening document
and/or other methods of consent notication, provide for the dispatch of marketing information relating to services or
products offered by DCS whether by DCS, DCS’s afliates, business partners or related companies which DCS thinks is of
benet or interest to me/us via my/our consented method(s) of communication; (m) processing any applications or requests
for new services and/or products made by me/us; (n) enforcing my/our legal and/or contractual rights against me/us; (o)
maintaining the safety and security of DCS’ premises with the use of security cameras; (p) seeking professional advice
(including but not limited to obtaining legal advice and facilitating dispute resolution); (q) conducting checks with the Do
Not Call Registry; (r) administrating loyalty and rewards programs (including but not limited to the processing of redemption
vouchers, benets or entitlements); (s) managing DCS’ business operations and complying with DCS’ internal policies and
procedures; and (t) processing my/our application for Card Account(s), services and products by DCS (collectively, the
“Permitted Purposes”). I/We consent to DCS collecting my/our personal data from DCS’ business partners and for such
business partners to disclose my/our personal data to DCS for the purpose of managing and administrating any benets
I/we may enjoy as DCS’ cardholder. DCS shall not use, disclose and/or process my/our personal data for purposes which
are not stated above. Should DCS wish to use, disclose and/or process my/our personal data for a new purpose, DCS will
notify me/us and seek my/our prior written consent. Notwithstanding the foregoing, I/we may withdraw my/our consent for
DCS, and any of its ofcers, employees, agents, contractors or service providers to process, collect, use and/or disclose
my/our information for one or more of the Permitted Purposes at any time by writing to DCS, telephoning DCS or sending
an email to DCS at DCS’ address or number on the Website. Where necessary, DCS may disclose my/our personal data
to DCS’ franchisees worldwide; any credit bureau of which DCS is a member or subscriber and/or to any other members,
subscriber and/or compliance committee of such credit bureau and to any other person to whom disclosure is permitted
or required by any statutory provision or law; or DCS’ third party service providers and agents (including its lawyers/law
rms), (whether located in or outside Singapore) for any of the Permitted Purposes only. DCS shall not disclose my/our
personal data for purposes for which I/we have not obtained consent.
3. (a) am/are aware that if DCS approve the application made herein, the Card(s) will be issued by DCS subject to DCS’s
terms and conditions indicated herein and to its other terms and conditions for issuance of Credit Cards;
(b) am/are aware that the terms and conditions of issuance of Credit Cards can be inspected at DCS’s ofce and a copy
will be despatched to me/us with the Card(s) and I/we agree to be bound by them upon receipt or acceptance of or signing
on or use of the Card(s) unless the Card(s), cut into half, is/are returned to DCS.
4. agree that the Card(s) may be sent to me/us at my/our risk by ordinary mail to my/our billing address.
5. agree that the Basic Card Applicant is and shall be responsible for all charges/liabilities (including Annual Fees or any
other fees/charges) which may arise out or be incurred in respect of the Basic Card and all Supplementary Card(s) issued
at the Basic Card Applicant’s request (if any) and each Supplementary Card Applicant is and shall be responsible for all
charges/liabilities (including Annual Fees or any other fees/charges) which may arise out or be incurred in respect of the
Supplementary Card.
6. conrm that at the time of this application, I am/we are not under the Debt Repayment Scheme or undischarged bankrupt
and no statutory Demand nor any legal action process has been served on me/us.
7. authorise DCS, if this application is or is purported to be given or sent by me/us to DCS by electronic transmission, to rely
on and process this application in accordance with the submitted copy of the form, though DCS is not obliged to do so,
without waiting for the original signed form. I/We will submit to DCS the original signed form even though the Credit Card(s)
had been issued in accordance with the submitted copy if DCS requests for the original form.
8. I understand that should my membership with the afnity organisation cease, I/we must return the Card(s) to DCS.
9. hereby warrant that the information given herein and all documents (if any) submitted are true and correct.
10. agree that DCS may decline this application at its sole discretion without assigning any reason.
11. consent to DCS sending me/us regular updates on Diners Club promotions/services including, but not limited to, discounted
offers and incentive programs by way of email and postal mail; and to the telephone numbers provided on this application
form, notwithstanding the fact that such numbers may be registered on the Do-Not-Call registry, by way of :
VOICE CALLS
[ Please note that if you do not tick this box, you nevertheless consent to DCS sending such updates by way of voice calls
if the telephone number you provided is not registered on the Do-Not-Call registry, or sending you updates by way of text
or fax messages by relying on the Singapore Personal Data Protection Act 2012. If you wish to withdraw your consent to
be contacted by DCS on the above updates, you may do so at www.dinersclub.com.sg. ]
- PLEASE SIGN AS YOU WOULD FOR ALL FUTURE TRANSACTIONS : -
SIGNATURE ______________________________
SIGNATURE ______________________________
of Basic Card Applicant & DATE
of Supplementary Card Applicant & DATE (if applicable)
Diners Club (Singapore) Pte Ltd Co. Reg No.: 197300502W
For BASIC CARD APPLICANT
(NOT applicable for Cobrand S$500 Limit Card Applicant)
PREFERRED CREDIT LIMIT
S$ .
0
0
Credit limit granted may be lower than indicated here. If not
indicated, DCS will determine the amount at its discretion.
The Credit Limit refers to the aggregate credit limit in respect
of all your Diners Club Card(s). Any credit limit increase will
not be applicable to existing Supplementary Cardholder(s) not
indicated on this application form, if any.
For SUPPLEMENTARY CARD APPLICANT
(if applicable)
PREFERRED CREDIT LIMIT
S$ .
0
0
Credit limit granted may be lower than indicated here. If not
indicated, the credit limit assigned will be the same and
shared with the Basic Cardholder. Approved credit limit will
be applied for all Supplementary Cardholders. Kindly ensure
that ALL Supplementary Card applicants have signed on
this form. Attach a second sheet if there are more than one
Supplementary Card applicant.
FULL NAME AS IN IC/PASSPORT (Please underline SURNAME)
GROSS ANNUAL INCOME
S$
HANDPHONE (MANDATORY)
ADDRESS (If different from Basic Card applicant; should not be a P.O. Box address)
NATIONALITY NAME OF EMPLOYER
RELATIONSHIP
IC/PASSPORT NO.
GENDER
OFFICE TEL POSITION HELD
+
PLEASE EMBOSS MY NAME AS FOLLOWS (MAX. 23 SPACES & INCLUDE INITIALS OF FULL NAME):
+
The proposed embossed name may be altered to comply with Diners Club’s card embossing specications.
Declaration - Please read before signing
My Supplementary Card
For my Spouse or Other Family Member ABOVE 18 YEARS OF AGE
DATE OF BIRTH ( YYYY / MM / DD )
ARE YOU A U.S. TAX RESIDENT? ^
NO
YES – Taxpayer Identication (TIN):
^
Denition: A citizen or permanent resident of the United States (eg. U.S. Green Card holder or someone who meets the requirements to be
considered a resident under the ‘substantial presence test’); or any other person that is not a foreign person (as dened under U.S. federal tax law).
Document to Submit: If you have stated that you are born in the United States but are no longer a U.S. Tax Resident, please submit either one
of these documents: Certicate of Loss of Nationality of the United States OR Form I-407 (Abandonment of Lawful Permanent Resident Status).
ARE YOU A U.S. TAX RESIDENT? ^
NO
YES – Taxpayer Identication (TIN):
Male
Female
Male
Female
