SUPPLEMENTARY CREDIT CARD APPLICATION

(Liability of the Supplementary Credit Card will be on the Primary Card Member)
PRIMARY CARDHOLDERS DETAILS:
Name
Card Account:
Supplementary Card can be issued to family members (Over 18 years of age) of the Primary Card Member
Please issue a Supplementary Card for my*
Spouse

Father

Mother

Son

Daughter

Brother

Gender

Male

Sister

Name*
Date of Birth*

Female

Third Gender

Name as desired on the Card*

(Maximum 19 characters, including spaces)

Current Residential Address*

Apartment/Building name
Floor
Street / Road
Landmark
City*

House/Plot no.

Sector / Locality

Pin*

State*
STD code*

Tel.*

Mobile*

E-mail ID (Personal)*
I would like to set the refresher limit (spend limit on the Supplementary Credit Card set by the Primary Card Member which is refreshed at billing cycle)
for the Supplementary Credit Card at
(multiples of 000 only)

** Instructions Please enclose the following documents

A self-attested copy of proof of identity (any one of the following)*
Passport

Voters ID

Driving License

PAN Card

Aadhar Card

Government ID Card

A self-attested copy of proof of residential address (any one of the following)*

Passport

Voters ID

Utility Bill

Aadhar Card

Driving License

Bank Statement

1. Utility bill, which is not more than two months old of any service provider - electricity, telephone post-paid mobile phone, piped gas, Water bill
2. Bank account or Post Office savings bank account statement
3. ID & Address Proof needs to be ticked out of the options provided
We confirm that the information given is true and correct. We understand the Primary Card Member will be liable for all the charges incurred with the Primary Card
and the Supplementary Card. We jointly and severally agree to be bound by the Rules and Regulations of use of the Credit Card, copy of which we have received
and understood. In particular, we confirm the usage in strict accordance with the Exchange Control Regulations of the Reserve Bank of India. We understand that
in the event of failure to do so, we are liable for action under the Foreign Exchange Regulation Act, 1973 and may be debarred from holding the ICICI Bank Credit
Card, either at the instance of ICICI Bank or the RBI. We authorise ICICI Bank to verify information in this application and to receive or exchange information about
us with other banks, agencies, companies for marketing and administrative purpose or for prevention of frauds, etc.

Signature of Add on Applicant (please sign across the Photograph)

Please send colour Photograph (s) only. This would be retained by us for our records. Please do not use pins, tapes or staples to affix your photograph.

Signature of Primary Card Applicant

Date

*Please provide separate self-attested documents for proof of identity and proof of residential address. Only a valid Passport will be accepted in both cases.
At any given point of time, a maximum of up to 3 supplementary cards will be issued to a Primary Card Member including any supplementary cards issued against
any other ICICI Bank primary credit card.
**As per provisions of Reserve Bank of India Master Circular (RBI/2009-10/73; DBOD. AML. BC. No. 2/14. 01. 001/2009-10) on Know Your Customer (KYC) norms
dated 01 July 2009, it is mandatory for all banks to update the customer identification documents (including photographs). Please submit the completed form along
with the documents to the nearest ICICI Bank branch.