American Express Name Change Form – Fill Out and Use This PDF

NAME CHANGE AUTHORIZATION FORM

Please complete all applicable fields and return the form to the address listed at the bottom of this page. Also, please be sure to include a copy of the supporting document(s) issued by a provincial or territorial government authority in Canada evidencing the name change. For examples of supporting documents please see back page. You must complete a separate form for each account affected by the name change. Forms may be submitted together with one copy of the supporting documentation.

ACCOUNT INFORMATION

Account Type:

[ ] Credit or Charge Card

Account Number:

Who is the name change request for?

[ ] Basic Cardmember

BASIC CARDMEMBER INFORMATION

Original Name:	________________________________________________________
	(First Name)	(Middle Initial)	(Last Name)
Name Changed to:	________________________________________________________
	(First Name)	(Middle Initial)	(Last Name)

Address: _____________________________________________________________________

(Street Name)

______________________________________________________________________________

(City)(Province)(Postal Code)

SUPPLEMENTARY CARDMEMBER INFORMATION (if applicable)

Original Name:	_______________________________________________________
	(First Name)	(Middle Initial)	(Last Name)
Name Changed to:	_______________________________________________________
	(First Name)	(Middle Initial)	(Last Name)

SIGNATURES

I certify that the attached document(s) are true copies of the original(s), that my name has changed as set out above, and I request that Amex Bank of Canada update its records and, if applicable, issue replacement Card(s).

The Basic Cardmember’s signature is required to change any account information. If the name change is for a Supplementary Cardmember, both Basic and Supplementary Cardmember signatures are required.

______________________________	______________________________	________
Basic Cardmember Signature (Before Change)	Basic Cardmember Signature (After Change)	Date
______________________________	______________________________	________

Supplementary Cardmember Signature (Before Change)

Supplementary Cardmember Signature (After Change)

Date