American Express Corporate Application Form – Fill Out and Use This PDF

Employee:

*Required fields must be completed or application cannot be processed.

Please complete and send to Program Administrator listed on application.

Program Administrator:

*Required fields must be completed or application cannot be processed.

Please complete and send to: American Express P.O. Box 53816 Phoenix, AZ 85072

Or

Fax to:

623-492-3884

American Express® Corporate Card Application

Application Information - Application cannot be processed without required information

Name as you would like it to appear on the Corporate Card (20 characters maximum, including spaces - *Required)

Billing Street Address *Required (20 characters maximum, including spaces)			Home	Office
City (17 characters maximum, including spaces)		State	Zip Code
Home Street Address *Required (if different than billing address)
City (17 characters maximum, including spaces)		State	Zip Code
E-mail Address (**Required)
Social Security Number (*Required)		Home/Personal Phone Number(*Required)
-	-	-		-
Business Phone Number (*Required)			Fax Number (*Optional)
-	-	-		-
Employee ID Number (10 characters maximum)		Cost Center Number (10 characters max.)

Universal Number (25 characters maximum)

Please read the Agreement before signing.(*Required)

By signing above I indicate my acceptance of the terms and conditions of the Agreement.

X

Date

Program Administrator - Application cannot be processed without required information

Basic Control Number (*Required - please fill out or application cannot be processed)

Company Name (20 characters only, including spaces)

Authorizing Signature* Please read the Agreement before signing.

I am authorized to complete this enrollment authorization on behalf of the company

X			Date
PRINT Authorizer’s Name		Title
Phone Number			Fax Number
-	-	-	-
PRINT Program Administrator Name * May be previously filled out by PA			PA Phone Number
		-	-

* All applications require a signature (name & title) of an authorized Company Representative or Program Administrator.

AGREEMENT:

Company and the Applicant (a) request that a Corporate Card be issued to the Applicant on the Companys account, (b) authorize the receipt and exchange of credit information on the Company and the Applicant, (c) agree to be bound by the Agreement sent with the Card and by the agreements covering Corporate Card related programs in which the Applicant is enrolled, and (d) agree that the Corporate Card will be used for business or commercial purposes only. The Applicant (a) authorizes American Express to notify the Company if this application is declined or if spending restrictions are applied to the Corporate Card, and (b) agrees to be liable for payment to American Express of all amounts charged to the Corporate Card.

**We may notify you about important account updates and services that may be suited to your needs. We will never share your email address. For information about how we protect our privacy, please visit americanexpress.com/privacy