ADDITIONAL CITIBANK CARD APPLICATION FORM

NOTE: Additional credit card annual fee - Nil. You can apply for a maximum of 5 additional credit cards (linked to your primary card) for your family members. Since this form provides slots for 3
addon applicants, please download another copy of the application form if your wish to apply for more than three additional cards.
Name of Primary Cardmember PRIMARY CARDMEMBER DETAILS (Please tell us about yourself)

First Name Middle Name Last Name

Citibank Card Number

“I understand that I can get an Additional Card for my Resident Indian/Foreign National parent, parent-in-law, spouse, brother, sister or child over 18 years of age at a special rate. The Additional Card
fee, as applicable per the offer, will be billed in my Statement. I agree that it will be my responsibility to provide identity and address or any other additional documents and/or information of the Additional
Cardmember that may be required by Citibank in future. I understand that I am liable to honour all charges incurred on the Additional Card. I accept that use of the Additional Card by the Additional
Cardmember constitutes acceptance of the terms of use of the Cardmember Terms & Conditions as amended from time to
time and constitutes an undertaking from the Additional Cardmember that the usage of the Card shall be in accordance with
the Exchange Control Regulations of the Reserve Bank of India and the Foreign Exchange Management Act, 1999 and that
failure to do so would make the Additional Cardmember liable for action under the Foreign Exchange Management Act, 1999.
I accept that the facility of an Additional Card will stand automatically terminated in case of termination of membership of the
Primary Cardmember.”
Issuance of Additional Card will be subject to eligibility and the Bank's internal processing criteria.
Signature of Primary Cardmember and Date (Existing Cardmember only) Date:
Please send across the duly filled application form along with the applicant's identity documents to Citibank N.A. Mail Room, No. 2, Club House Road, Chennai - 600 002.

ADDITIONAL CARDMEMBER DETAILS

Additional card applicant's age at the time of applying should be between 18 and 70 years.
Please annex a self-attested copy of any one of the following valid photo identity documents of the Additional Card Applicant(s) with this application - PAN Card,
Passport, Driving License, Ration Card, Voter's ID Card, ID Card issued by recognised schools/colleges (applicable for students only).

1. Name of Additional Cardmember (Please restrict to 26 characters including all spaces)

2. Date of 3. Sex: Male Female

D D M M Y Y Y Y
Birth:
Mandatory
4. Relationship: Spouse Child Sister Brother Father Mother Father-in-law Mother-in-law
Please paste a recent
5. PAN/GIR passport size colour
Number: 6. Mobile no: photograph of the
Additional Applicant
here. Please do not
7. Email: use pins, tape
or staples on the
photograph.
8. I confirm that the Additional Card Applicant resides at the same address as mine.

9. Do you wish to apply for a Photo Card*?: Yes No Signature of Primary Cardmember

1. Name of Additional Cardmember (Please restrict to 26 characters including all spaces)

2. Date of 3. Sex: Male Female

D D M M Y Y Y Y
Birth:
Mandatory
4. Relationship: Spouse Child Sister Brother Father Mother Father-in-law Mother-in-law
Please paste a recent
5. PAN/GIR passport size colour
Number: 6. Mobile no: photograph of the
Additional Applicant
here. Please do not
7. Email: use pins, tape
or staples on the
photograph.
8. I confirm that the Additional Card Applicant resides at the same address as mine.

9. Do you wish to apply for a Photo Card*?: Yes No Signature of Primary Cardmember

1. Name of Additional Cardmember (Please restrict to 26 characters including all spaces)

2. Date of 3. Sex: Male Female

D D M M Y Y Y Y
Birth:
Mandatory
4. Relationship: Spouse Child Sister Brother Father Mother Father-in-law Mother-in-law
Please paste a recent
5. PAN/GIR passport size colour
Number: 6. Mobile no: photograph of the
Additional Applicant
here. Please do not
7. Email: use pins, tape
or staples on the
photograph.
8. I confirm that the Additional Card Applicant resides at the same address as mine.

9. Do you wish to apply for a Photo Card*?: Yes No Signature of Primary Cardmember

*Only select card types have the Photo Card option. Your choice will be processed based on the availability of the Photo Card feature on your card. (Version: Addon appln_ V2_June 2010)

add on application form - size: A4 - June - 2010