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Legislative Assembly for the ACT: 1999 Week 6 Hansard (22 June) . . Page.. 1675 ..
AMERICAN EXPRESS GOVERNMENT CARD
- CARDMEMBER APPLICATION FORM
Please ensure all the application details are completed to speed up the application process and
fax this completed form to American Express on (02) 886 1151
1. AGENCY DETAILS: PD51100301 3. Office Use Only
Telephone: CAN/DEC ( ) FEE ( ) DELIV ( ) Programme Administrator's Name: REV ( ) BILLING ( ) SEX ( ) Cost Centre name: DIRDEB ( ) PRES/PREV ( ) XREF RSN ( ) Agency I.D.: SIGN ( ) CB REPORT ( ) Your internal Ref No(if Req'd) 4. Declaration by applicant
2. EMPLOYEE DETAILS I, the Government Card applicant, hereby apply
to you (American Express International Inc.) for
Surname: an American Express Government Card. If
issued to me, I agree to use that Government
Card solely for business purposes. I certify that
Given name: the information given above in support of my
application is true and correct.
Please Tick. A. Mr ( ) Mrs ( ) Miss ( ) Ms ( ) Dr ( ) The following is pursuant to the Privacy Act:
Other( )Please specify: I acknowledge and agree that both you and my
B. Male( ) Female( ) employer shall have access to all
out of the use of the Government Credit Card
Employee's name as it is to appear on the Government Card: issued to me. I certify that each Government
Card applied for, approved and issued under this
application will be used solely for business
(Note: Only 22 characters available including spaces.) purposes.
Business Address (where you work):
Signature of applicant
Postcode:
Date
Business Telephone:
5. DECLARATION BY AGENCY
SIGNATORY
Position in Agency:On the behalf of the Agency (has the same
Mailing Address: meaning as provided for in the contract) named
in the application (the "Agency"), I hereby
Postcode: request issuance of a Government Card to the
individual named above and certify that the
Date of Birth: named individual is an employee of the Agency.
I confirm that the information given this
Please tick: application form is to the best of the Agency's
Federal Government ( ) knowledge true and correct and that the Agency hereby agrees
to be bound by the American Express Government
State Government ( ) Card Cardmember Terms and Conditions (where applicable)
with respect to such Government Card.
Signature of Authorised Officer
Date
Name:
Position:
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