CreditCardApplicationForm信用卡申请表

信用卡申请表Credit CardApplication FormTheminimum ageto applyfor acredit cardis18years old.Please completethe applicationform inEnglish andBLOCK LETTERS,，tick amark whereapplicable.Incomplete applicationscannot beprocessed.申请人须年满周岁请使用英文填写所有空格并连同所需文件一同递交给本行,不能受理欠缺完整的申请表18The Bank may consultthe CentralCredit RegistrationOffice BureauKrediet Registratie,BKR inTiel根据实际情况,我行可能会通过查询客户信用记录BKR BureauKrediet Registratiete Tie重要信息

1.CREDIT CARDINFORMATIONSupplementaryRepayment dateMinimumIncome/Year Principal Card Annual附属还款日Card AnnualFee*Card type卡种最低年收入Fee*主卡年费*卡年费*普通卡Classic Card/EUR

20.000,00EUR24EUR1210金卡Gold Card/EUR

28.000,00EUR24EUR1225白金卡Platinum Card/EUR

60.000,00EURO EURO25如有修改将会另行通知阁下*Customer will be informedif changesoccurREQUIRED DOCUMENTS:

1.Photocopy ofboth the Principal andSupplementary Applicantsidentification documentincluding evidenceof yourBSNFor Employed:For Not-employed applicants-Photocopy of a validemployment contractor employersdocument proof-Photocopy ofcapital assetmaterials includingproperties,bank savings,-Photocopy of the latest3month pay-slip orbank statementsshowing thesalary stocks,funds,amount-bonds,gold,investment based-insurance orother investmentproducts ForForSelf-employed:Non-permanent resident:-Photocopy of the Businessregistration certificate;and-Photocopy ofresidence permitor workpermit withat least9months validity-Latest sixmonths IncomeTax lnvoiceapplicablefor businesspaying at the timefixedincome taxor TaxReturns-Application orEmployment confirmationletter for the next9months.-for thelast2years applicablefor businesspaying normalbusiness incometax;and-Latest6months majorbank statementin thename of the business所需文件

2.Photocopy ofcurrent addressproof includinga copyofatax letter,bank statementwithout balance,or letterfrom municipality

1.主卡和附属卡申请人的身份证明文件（包括税号证明）

2.附有申请人姓名之最近3个月住址证明，包括纳税证明、银行对账单或市政厅来信作为住址证明工作收入人士自雇人士•有效的雇佣合约或雇主出具的证明文件•公司之商业登记证;及•最近三个月的工资单或有显示出量记录的银行月结单•最近六个月纳税证明（适用于公司以探用固定入息缴税方法）非在职人士•或最近）二年的纳税证明（适用于公司探用一般利得缴税方法）;及一个人资产证明文件包括房产（物业），银行存款，股票，基金,•最近六个月的公司主要银行往来记录证明・债券，黄金，投资理财型保险或其他投资产品等非永久居民人士:■在申请时居留许可证明或工作许可证明最少九个月的有效期或在■未来9个月依然有效的工作证明文件复印本申请卡类型□MASTERCARD CLASSIC万事达普卡Type ofCredit Cards/□MASTERCARD GOLD万事达金卡SINGLE CURRENCYEUR万事达白金卡□MASTERCARD PLATINUMPledge单币卡欧元申请信用限额Preferred Credit Limit EUR川您If youhold anaccount withICBC EuropeS.A.Amsterdam Branch,please fin yourcustomer,-card,-or accountnumber在工行阿姆斯特丹分行的客户号码、卡号或账号质押办卡口card applicationDYes1\1CHINA UNIONPAYDUAL CURRENCYEUR/RMB双币卡欧元/人民币□CHINA UNIONPAYCLASSIC专艮联普卡□CHINA UNIONPAYGOLD银联金卡□CHINA UNIONPAYPLATINUM车艮联白金卡□Ms.申n请iVI人rs个.口人1资71料匚nDr.

2.PERSONAL DETAILSBasic information基本资料□Male男IZlFemale女称呼Title性别Gender姓姓名与身份证/护照一Surname Name on ID card/Passport致中间名*Prefix名名与身份证/护照Given NamesName on ID card/Passport一致Preferred Name on CreditCard显示在信用卡上的姓名（不超过个字母包括间隔）19出生城市:Place ofBirth出生国家Country ofbirth（）出生日期（日日/月月/年年）Date ofBirth DD/MM/YY国籍Nationality证件类型:Type ofIdentity证件号码Identification documentnumber身份证/护照签发国家Issued Place/Country（）发行日期（日日/月月/年年）Issue Date DD/MM/YY（）证件有效期（日日/月月/年年）Expiry DateDD/MM/YY税号Personal Identificationnumber/BSN number学历Education Level小学或以下□Primary Schoolor below初中□Junior HighSchool高中□Senior HighSchool学士□Bachelor degree硕士或以上□Master degreeor above其他□Others只适用于中国公民Only forChinese residents中国身份证号码:Chinese IdentificationNumber中国身份证上的中Name onChinese Identification document居住情况Residents Detail居住土也址Address street+number邮区号，城市:Postal Codeand city国家Country住宅:Residential Type自置□Self-Owned按揭□Mortgage租用□Rent联系方式Contact Detail□□MLIiavDirnictgaarlwdSit身thaP份tuas证re婚nt姻s/r状el况atives与父母/亲属同住文姓名1单身□□□OPS thainesg rsslpe其ort他护照已婚□Married居留卡□Residence Permit□Divorced离婚驾驶证□Driving License其他,□Other.住家电话号码Telephone numberhome+31公司电话号码Telephone numberwork+31手提电话Mobile number+31电邮地址@Email申请人职业资料

3.EMPLOYMENTFINANCIAL DETAILS现公司名称Company name职衔/职业Job Title/occupation受雇年资日日/月月/年年Date ofEntrance MM-YYYY受雇性质Employment Status自雇人士□Self-Employed全职，□Full-time employed合约到期日日/月月/年年如适用please fillin theend ofcontract dateMMYYYYonly ifapplicable兼职，月兼职多少小时，□Part-time employedContract hoursper month合约到期日日/月月/年年如适用please fillin theend ofcontract dateMMYYYYonly ifapplicable退休□Retired家庭主妇，请直接跳到第四点“通讯地址”□Housewife pleaseproceed tosection

4.correspondent address失业，请直接至第四点“通讯土也址”□Unemployed pleaseproceed tosection

4.correspondent addressEK U其他□Others公司业务性质Business Type金融教育服务□Banking/Finance□Education Services保险公共事业管理□insurance□Public Administration专业服务进出口贸易□Professional Services□import andExport Trade通讯与科技口附助医疗保健和社会活动□ITCommunications2care andSocial Activities建筑和工程口食品和饮料服务业□Building andConstruction501and Beverageservices政府部门口酒店□Government1~10131制造房地产及租赁□Manufacturing□Real Estate,Rental andLeasing零售口由建其他□Retail0当雇职位Current Position公务员口亿主任□Civil Servant0£3r专业技术人员行政/文^人具□Professional□Administrator7clerical自雇/企业拥有人技能劳工/技术员□Business Ownernskill Labour/Technician教授/教师非技术劳工□Professor/Teacher□Non SkillLabour董事/总裁/总经理警察/军人□Director/CEO/GM□Police/Military高级管理人员口厨师□Senior Managerial31/03£初级管理人员口口的「司机□Junior Managerial6销售口年其他□Sales0m3现公司联系详情Current CompanyContact Detail公司土也址Companys Address street andnumber邮区号,城市Postal Codeand City国家Country公司电话Telephone numberwork.+31公司传真Company Faxnumber+31Previous Companys Address Ifyou workfor lessthan6months atthe currentcompany前受雇公司地址若您在现公司工作的时间少于个月6公司名称Company name公司土也址CompanysAddressstreet andnumber由区号，城市Postal Codeand CityR国家Country公司电话Telephone numberwork公司传真Company Faxnumber财务状况Financial information总年薪Gross AnnualIncome includevacation money,13th其他年收入:Other AnnualIncome EUR其他收入来源Source ofOther AnnualIncome EURMonthly每月租金rental amount/mortgage paymentamount Total每月固定支出monthly FixedSpending e.g.utilities

4.CORRESPONDENT如没Home addresswill beselected ifno instructionis given居住地址办公室地址□Home Addressnoffice Address其他□Other邮区号城市Postal CodeCity5,REPAYMENT Z账户号码:Account number*Please ensurethat thereis sufficientamount in the accoun*payment penalty.The monthlyrepayment amountwill be the请确保扣款账户有足够的余额备扣每月还款，以免因延误交流部透支金额

6.SUPPLEMENTARY CARI称呼Title性别Gender姓姓名与身份证/护照一Surname NameonIDcard/Passport致中间名*Prefix名名与身份证/护照Given NamesNameonIDcard/Passport一致Preferred nameon CreditCard显示在信用卡上的姓名（不超过个字母）19出生城市Place ofBirth出生国家Country ofbirth（）出生日期（日日/月月/年年）Date ofBirth DD/MM/YY国籍Nationality证件类型Type ofIdentity证件号码Identificationdocumentnumber身份证/护照签发国家Issued Place/Country（）发行日期（日日/月月/年年）Issue DateDD/MM/YY（）证件有效期（日日/月月/年年）Expiry DateDD/MM/YY税号Personal Identificationnumber/BSN number只适用于中国公民Only forChinese residents）身份证i m+□3o1indtehnetitfcic.ationEcUarRd护照+□31Passport居留卡□Residence Permit“按揭供款金容昆EU驾R驶证□Driving License（如水电费用其他EUR□Others「通讯地址ADDRESS:有选择，符代卷设定居住地址国家Country还款账户ACCOUNTit for the monthlyspending repaymentso asto avoidany lateJwholeoutstanding onyour bankstatement.求导致滞纳金罚息的产生月还款金额为月度对账单中的全附属卡申请人详情D DETAILS口匚口口匚□Ms.QMrs.1\/1男口女□Male5012©中国身份证号码Chinese IdentificationNumber中国身份证上的中文姓名:NameonChinese Identificationdocument与主卡申请人的关系Relationship toPrincipal Cardholder配偶未婚妻侏婚夫□Spouse Fianc6口父母口亲属Parent Relatives儿子/女儿□ChildrenResidential addressonly Homeaddress andnumber isdifferent fromthePrincipalCard applicant居住地址若不同于主卡申请人居住土也址Addressstreet+number邮区号,城市:Postal Codeand city国家Country住家电话Telephone numberhome+31手提电话Mobile number+31信用限额

7.CREDIT LIMITFOR SUPPLEMENTARYCARD附属卡的信用限额分配CreditLimitAssignment forSupplementary CardApplicant会，本人壬见分配附属卡申请人的信用额度为□Yes,for thisSupplementary Cardapplicant,I wouldlike toassign acredit lineof欧元EURo川不会，我们将分享核定信用额度□No,we wshare theapproved creditline.声明与协议

8.DECLARATION OFAPPLICANTS中文翻译在英文版之后You canfind theChinese Declarationunder theEnglish version注意请仔细阅读后再签名IMPORTANT:PLEASE READBEFORE SIGNING1l/We confirmthat theabove informationis true,complete andaccurate.I/We herebyauthorise Industrialand CommercialBank of China AmsterdamBranchthe Bank to contactmy/our employers,financial andcredit institutionsor anyother creditor informationsources for the verification thereof andfor thecollectionof suchinformation asrequired forthe processingand evaluationof this application and,if my/our applicationis approved,forthe operation of my/our accounts.2The Bank may acton instructionsfor operatingthe accountsgiven byme/us,the AuthorisedPersons namedif anyor byway ofAuthorised Impressionifany,until the Bank*s actualreceipt ofmy/our revocationor amendmentthereof inwriting.The bankis entitledto assumeat alltimes,the legalityand genuinenessof the AuthorisedPersons andAuthorised Impressionwithout verification.I/We shalltake allresponsibility for any loss,liabilities ordamage ofwhatsoever natureresultingtherefrom.3I/We understand and agree that thecard processingand thecard embossingactivities inrelation to the Cardwillbeconducted byICBC CreditCard CentreIntlestablished inHong Kong,and otherservice providersof the Bank inMainland Chinaunder strict security measuresand operationalcontrols toensure thatanyinformation of the cardmembersbe keptstrictsecurityconfidential andwill not be disclosedto any third partywhetherin theNetherlands orelsewhere,exceptas requiredby law,or withmy/our consent.I/We herebyalso consentto thedisclosure ofmy/our informationto theservice providersof the Bank forthe purpose ofproviding thecard processingand thecard embossingservices tothe Bankby suchservice providers.4I/We agreethat the Bank reservesthe rightto requestother supportingdocuments fromme/us.5I/We herebysolemnly andsincerely declarethat iI/We havenever beenadjudged bankrupt,or madethe subjectof anybankruptcy or similar proceedingsorof receivershipsorsimilar order,in theNetherlands orelsewhere;and iiI/We havecarefully andconscientiously consideredthe statusofmy/our assetsandliabilities.I/We haveno intention to petitionfor my/our ownbankruptcy orforanysimilarorder,or proposeto enterinto withmy/our creditorsany individualvoluntaryarrangement orsimilar arrangement,intheNetherlands orelsewhere,nor doI/We seeany reasonwhy I/We shoulddo so.6I/We understandthat ifI/We knowinglymake anyfalse statementin my/our applicationwith anintentiontodeceit,I/We may be liable for criminalprosecution.7I/We furtherauthorise theBank todisclose anyinformation regardingme/us and/or this application and/or my/our accountswith theBank confidentiallyto ithe Banks employees,agents andcontractors forthe purposeof processingand verifyingthisapplication;ii thirdparties retainedby theBanktoprovide servicesinconnection with theoperationof customeraccounts includingcredit checkand debtcollection serviceand marketingof accountservices;iii IndustrialandCommercial BankofChinaLimited andits subsidiaries;and ivanythird party whosename orlogo appearson the Card.I/We alsounderstand andagreethattheBank maytransfer toand usemy/our datain otherplaces atany timeand fromtime totime wheretheBankdeems necessary.I/We alsounderstandandagree thattheBankmayuse theinformation regardingme/us and/or my/our account（s）withthebank formarketing thefollowing services and products（in respectof whichtheBankmayor maynotberemunerated）:-（i）financial,insurance,credit card,banking andrelated servicesand products;（ii）reward,loyalty orprivilegesprogrammes andrelated servicesand products;and（iii）servicesandproducts offeredby theBanks co-branding partners;and theseservices orproducts maybeprovided and/or marketedby:（i）theBank and theBanks groupcompanies;（ii）third partyfinancial institution,insurers,credit cardcompanies,securities andinvestmentservices providers;（iii）thirdpartyreward,loyalty orprivileges orprogramme providers;and（iv）co-branding partnersoftheBankandtheBanksgroupcompanies.I/We understandthat l/We havethe rightto optout ofsuch marketingprograms.8I/We agreeto bebound by the terms and conditionsoftheCardmember Agreementand anyfurther amendmenton thetermsandconditions thereafter,acopy ofwhich willbe sentto me/us withtheCard.9I/We havecarefully readand fullyunderstand theMajor Termsand ConditionsoftheCardmember Agreementenclosed onthisapplicationform.NOTES:1Either thePrincipal orthe Supplementary Cardmember canrequest thetermination andsuspension ofthe SupplementaryCard.Upon suchrequest,the Cardmustbe returned totheBank assoon aspossible.Principal Cardmembershall remainliableforany paymentsarising fromthe useoftheCard andany relatedchargesuntil theCard isreturnedtotheBankortheBank isable toimplement theprocedures whichapply tolost cards.2The Bankmay,forthepurposeofthe application,conduct acredit reviewontheapplicant byaccessing thecredit referenceagencys database.3Approval/Rejection ofthe application,assignment ofcredit limit（s）and correspondinginterest rate（s）shall beatthesole discretionoftheBankwithout givingany reason.4Any documentssubmitted totheBankwill notbe returnedto me/us andadditional documentsmayberequested（when necessary）bytheBank uponprocessing.1以上资料均属详实，本人（等）授权中国工商银行阿姆斯特丹分行（“贵银行”）向本人（等）的雇主（“雇主”）、财务机构及信用咨询公司或任何其它信用状况或资料来源查询核实以上数据，并收取该等数据用以处理及评核申请，并在本人（等）的申请获批港后，用以操作本人（等）的户口2本人（等）声明及确认，贵银行可根据由本人（等）获授权人仕（如遹用）或以授权盖印方式（如遹用）所发出的指示处理账户，直至贵银行实际收到本人（等）以书面形式撤销或更改该等指示为止贵银行有权在任何时候假设获授权人仕及授权盖印的合法性和真实性本人（等）对因此而引起之任何性质之损失、责任或损害负上全部责任3本人（等）明白及同意贵银行信用卡处理及打卡过程由香港成立的工行信用卡中心（国际）及由贵银行设于中国内地的外判服务者进行，并由严密保安系统及运作程序监管，确保客户资料绝对保密，除法律规定或经本人（等）同意外，绝不会向第三者（不论是否处于荷兰）披露本人（等）同意就为信用卡处理和打卡的目的，贵银行可披露本人（等）的资料予贵银行之信用卡处理及打卡外判服务提供者4本人（等）明白及同意贵银行有权要求本人（等）呈交其它文槽5本人（等）谨此郑重及真诚地作出如下声明（i）本人（等）从未于荷兰或任何其它地方，被宣告破产，或成为任何破产案件或相类似的法律程序的被申请者，或受任何接管令或相类似命令的约束；及（ii）本人（等）已经小心及谨慎地考虑过本人（等）的资产及负债情况本人（等）并无任何意图，于荷兰或任何其它地方，申请本人的破产令或相类此的命令，或向本人（等）的债权人作出任何个人自愿安排或相类此的安排的建议，而本人（等）亦不觉得有任何理由需要提出任何上述申请或建议6本人（等）明白若在此申请中蓄意作出虚假陈述意图行骗，本人可能受刑事检控7本人（等）并授权贵银行向下述者披露本人（等）及/或此项申请及/或本人（等）的户口之任何资料，可获披露及可运用数据者为（i）贵银行聘用之员工、代理人及承包商，用以处理及核实此申请；（ii）贵银行聘请的服务提供者，对客户账户的操作（包括信用管理服务）和账户服务之市场推广有关之服务；（iii）中国工商银行及其附属机构及（iv）在信用卡上出现其名称或标志的第三者本人（等）亦明白及同意贵银行在任何地方和时间可利用本人（等）之数据及/或本人（等）于贵银行户口之数据作以下服务及产品的市场推广用途（不论银行是否从中获取酬劳）-（i）财务、保险、信用卡、银行及相关服务及产品；（ii）奖赏、回馈或优惠活动及相关服务及产品；及（iii）银行的联营伙伴提供的服务及产品；及此类服务或产品可能会由以下人士提供及/或推广（i）银行及银行的集团公司；（ii）第三者财务机构、保险公司、信用卡公司、证券及投资服务提供者；（iii）第三者奖赏、回馈或优惠活动提供者；及（iv）银行及银行的集团公司的联营伙伴本人（等）明白本人（等）有权选择不参与此类市场推广活动8本人（等）并同意完全遵守中国工商银行阿姆斯特丹分行信用卡会员合约即其后可能修订之条款（“该合约”），该合约将在申请获得批准后与卡一并发出给本人（等）9本人（等）己细心阅读并清楚明白随附于本申请表内的中国工商银行阿姆斯特丹分行信用卡会员合约的重要条款及细则请注意1主卡及/或附属卡会员均可提出暂停和取消附属卡在提出要求后，有关之附属卡应尽快退回本行在有关附属卡退回，或于本行可实施遗失信用卡处理程序前，主卡会员须对该附属卡发生之任何付款及有关费用支出负责2作为申请用途，银行将查阅资信调查机构的数据库，以进行申请人的信贷检讨3银行对此申请之审批/拒绝、信用额度及有关年利率将保留绝对决定权并毋须作出任何解释4所有提交给银行的文件均不获发还；而银行在申请过程中可能会要求申请人提供额外的证明文件（如有需要Place and date DD/MM/YY PlaceanddateDD/MM/YY地点、日期日日/月月/年年地点、日期日日/月月/年年SupplementaryCardApplicant Signature附属卡申请人签名PrincipalCardApplicant Signature主卡申请人签名（Please donot alter.If applicable,signature mustbethesame asthe specimensignature ofthe autopay instructionaccount请不要涂改如适用,该签字是自动转账指令的签字样本）工行用栏FOR BANKUSE ONLY申请表参考代码Application ReferenceCodeSales Code销售代码・・・--销售渠道Sales Channel银行柜台口集体销售口代理销售口・川检网上申请口・□1-Bank Counter2-Group Sales3-Agent Sales405电话销售口客户邮寄口口归（^直销口其它Telephone Sales6-Mail bycustomer7-Sale8-Other客户关系Customer relationship亲属朋友口・新客户（）其它□1-Relatives□2-Friends3New CustomerD4-Other pleasespecifySignature verified签名验证口1・丫3$有口2・No没有是否客户□是□否VIP身份证明文件验证:有口・没有Identification Documentverified□!-Yes2No备注（特另要求/结论）Remarks forspecial requirement/situation Ll分行代码Branch Code员工号码Staff Number负责人Personal incharge日期（日月年）DateDD/MM/YY。