Credit Card Application Form
Confidential
Applicant’s details
Title: Mr. Mrs. Miss Ms Other Specify
First name Middle name
Surname Mother’s maiden name Please affix
Nationality *National ID/Service no photograph
Passport no Marital status
Date of birth (ddmmyyyy) Place of birth (Town)
*Mandatory for Kenya citizens.
Address
Residential details
Physical address
Nearest landmark Town/City
Country
Postal address (Mailing address)
PO Box
Postal code Town/City
Email
Contact details
Mobile Work telephone
Employment Details
Employee details
Job title Name of Employer
Working since (ddmmyyyy) Industry/Sector
Monthly Net salary (Gross less Tax)
Employer details
Employer’s physical address
Town/City County
PO Box
Postal code Office telephone
Self employed
Position Nature of business
Years of operation Monthly turn over
Physical address
Nearest landmark County
PO Box
Telephone (H) Telephone (W)
Email
Absa Bank Kenya PLC is regulated by the Central Bank of Kenya. 1 AB KE IN 0000 (10/02/20)
Applicant’s banking details - Card repayments
Bank Account name
Account number Length of time with Bank
Card preference
Preferred Card
Payment insurance Yes No I would like Credit Shield Insurance protection Yes No
If “Yes”, please fill a separate insurance form.
Customer’s signature
Applicant’s existing loan and card commitments
Bank Outstanding amount/Credit limit Monthly repayment
Debt Service Ratio
Additional cardholder application
Complete this section only if you want us to issue a supplementary card (up to a maximum of 9) to another person (e.g. your spouse) as an
authorised user of your Absacard account. Remember, that as the principal cardholder, you will be liable for any usage by your authorised user. The
authorised user must sign this section where indicated.
Principal card account number
Title: Mr. Mrs. Miss Ms Other Specify
First name Middle name
Surname Mother’s maiden name
ID/Passport no (attach copy) Marital status
Date of birth (ddmmyyyy) Place of birth (Town)
Email Relationship to Cardholder
Telephone (W) Mobile
I accept and agree to be bound by terms and conditions accessible on the Absa website: [Link]
Date (ddmmyyyy)
Signature of Authorised User
Absacard payment method
By Auto Debit. How much? (min 5%) %
Note: Non-Absa customers must complete a separate form for inter-Bank direct debit payment.
Bank Account name
Account number
Instruction to Absacard
I/We authorise you to settle/pay my/our card account by auto-credit from my/our Bank account as stated above. I/We will inform Absacard in
writing if I/we wish to cancel this instruction. I/We understand that if any auto-credit is paid which breaches the terms of this instruction, the
Bank will make a refund.
All fields above are mandatory for Absa customers.
2
Absa Bank Kenya PLC is regulated by the Central Bank of Kenya
Referees
Relative 1
Name
Relationship to Applicant ID/Passport no
Email Mobile
Postal address
Relative 2
Name
Relationship to Applicant ID/Passport no
Email Mobile
Postal address
Card delivery/Statement account settlement
Please tick ( ) one
Payment option Option 1 Option 2 Option 3
Delivery method Branch delivery Courier delivery Preferred collection branch
Frequency of deduction Monthly Annually Payment date 5th 8th 14th 23rd 28th 30th
Please merge my statements via: (Choose one option)
Postal mail (charged) Personal address Email address
Customer declaration
Please issue a card to me and any additional cardholder indicated above. I warrant that the information given is true and complete, and I
authorise you to make any enquiries necessary in connection with this application. I accept and agree to be bound by the terms and
conditions of use (amended from time to time). I and any authorised user(s) agree that I/We are jointly and severally liable for all charges
incurred through use of each card.
I confirm that I have assessed my income and expenditure and I am able to service any debt I will incur from time to time against any card
issued to me.
I accept and agree to be bound by terms and conditions accessible on the the Bank’s website: [Link]
Date (ddmmyyyy)
Applicant’s signature
Signature no Date (ddmmyyyy)
Witnessed by signature (Branch official)
3
Absa Bank Kenya PLC is regulated by the Central Bank of Kenya
