National Geographic : 1980 Apr
FOLD, MOISTEN HERE, SEAL AND MAIL With this card S------ - r- -. American express Card Appicato PLEASE PRINT CLEARLY C C DB P PP B B 0 0 FS H PH Al R First,Middle, LastName Dateof Numberof Birth Dependents Soc. Sec. Number Street Address City,State andZip Code HomePhone Years Own Home D (AreaCode) There Rent0 Previous Years HomeAddress There City,State andZip Code NearestRelativeorFriend NotLivingWithYou Street Address City, State and Zip Code Relationship Employer orFirmName Natureof Business Years Position There Street Address City State and Zip Code Business Phone Self (Area Code) Employed 0 If Employed By Above Less Than 3 Years Previous Employer or College/University Yearswith Firmor GraduationDate Street Address City State and Zip Code Your Annual Earnings If less than $12,500 list other income, source and person (Banker, Broker, Employer, etc.) to whom we can write for confirmation. (Alimony, separate main tenance or child support need not be revealed if you do not wish to rely on it.) Amount Source Name Address List Credit Cards Account Number Other Credit Reference Bank(Company Accounts Show Company Banks) BankAddress City, State and Zip Code Type of Account Account Number Bank(Company Accounts Show Company Banks) Bank Address City, State andZip Code Type of Account Account Number *6*o _ So .b S i~ O PersonalAccount BillingAddress City, State and Zip Code o Present0 Former Account o None Number 0 Company Account Billto:0 Home O Office I - Printyour namebeow M t should FulM." Mu.t A not.xc.ed ... 042-00-0008-5 rulnrem1ntcdaaeee AN APPLICANT IF MARRIED, MAY APPLY FOR A SEPARATE ACCOUNT. By signing below, I ask that an account be opened for me and ifyou received areport, you will give me the name and address of Card s) issued as Irequest, and thatyou renewand replace them the agency that furnished it. until I cancel. I understand that you may verify and exchange Iwill be bound by the Agreement received with each Card, information on me and any supplementary applicants...includ- unless Icut the Card inhalf and return both halves to you. Ifthis ing requesting reports from credit reporting agencies, I am isa personal account, Iagree, or ifthis isa company account, aware that this information isused to determine my eligibility for both land the company agree, to be liable for all charges to the the Card and that, ifmy application isapproved you may contact basic and supplementary Cards issued on my request. In these sources to update this information at any time. IfIask addition each supplementary Cardmemberwill be bound by the whether or nota credit report was requested, you will tell me, and Agreement received with the Card and will be liable for all charges to that Card. Signature of Applicant Date For Company Account, Signature of Authorizing Officer Required Title x x Do not enclose $25 annual fee, or supplementary fee ($15 for Personal Account Supplementary Member ship,$25 for each Company Card). We will bill you later. ©1980American Express Company -A0 0 i A& ... .. _m . ...