it's easy to add an additional cardmember
Thank you for your recent request to add one or more additional
Cardmembers to your Diners Club Card Account. To add an
Authorized User, simply complete and sign the Additional Card
Request Form below, then return it by mail or fax.
COMPLETE THIS FORM IN ITS ENTIRETY AND FAX OR MAIL TO:
855 - 803 -7342
FAX:
MAIL : P
.O. Box 6101
Carol Stream, IL 60197-6101
For additional enrollments, please use a second form.
IMPORTANT TERMS
1. The Primary Cardmember remains responsible for all charges incurred by each Authorized User on the Account.
2. An Authorized User must be at least 18 years of age and be a permanent resident of the U.S.
3. C
lub Rewards points earned on purchases made with additional Diners Club Credit Cards, Diners Club Charge Cards and Carte Blanche Cards
will accumulate on the Primary Cardmember’s Account.
4. B
y signing below, the Primary Cardmember and each Authorized User agree to the terms and conditions of the Diners Club Credit Card
Cardmember Agreement, Diners Club Charge Card Cardmember Agreement or Diners Club Carte Blanche Card Cardmember
Agreement, as selected.
ADDITIONAL CARD REQUEST FORM
You may add additional users at a non-refundable, per-person annual fee of:
• $0 for Diners Club Credit Card
• $35 for Diners Club Charge Card
• $150 for Carte Blanche Card
FULL NAME OF PRIMARY CARDMEMBER: -
DINERS CLUB CREDIT, CHARGE OR CARTE BLANCHE CARD #:
AUTHORIZED USER FOR ADDITIONAL CARD #1
Mr. Mrs. Ms. MM/DD/YY
-
SOCIAL SECURITY NUMBER *
/
-
Mr. Mrs. Ms. /
DATE OF BIRTH
MM/DD/YY
/
-
-
SOCIAL SECURITY NUMBER
FULL LAST NAME *
FULL LAST NAME
FULL FIRST NAME *
M.I.
HOME ADDRESS
FULL FIRST NAME
M.I.
HOME ADDRESS
CITY
HOME PHONE #
-
AUTHORIZED USER FOR ADDITIONAL CARD #2
/
DATE OF BIRTH *
-
STATE
CELL PHONE #
ZIP
CITY
HOME PHONE #
STATE
ZIP
CELL PHONE #
*Required
By signing below, I certify that all information supplied above about me is true and complete and acknowledge that BMO Harris Bank N.A. will be relying on that information
in connection with the request for an additional Diners Club Card. I have read and agree to the Important Terms above.
SIGNATURE OF AUTHORIZED USER #1
SIGNATURE OF AUTHORIZED USER #2
Please issue Additional Card(s) on my Diners Club Card Account to the Authorized User(s) shown above who have signed this request form. By signing below, I certify that all
information supplied in this request form is true and complete and acknowledge that BMO Harris Bank N.A. will be relying on that information in connection with this request
to issue one or more additional Diners Club Cards on my account.
SIGNATURE OF PRIMARY CARDMEMBER
DATE
Diners Club International with the Split Circle Device, Diners Club, and Carte Blanche are registered trademarks of Diners Club International Ltd.
BMO Harris Bank ® and BMO Harris ® are trade names used by BMO Harris Bank N.A. Member FDIC.
© 2013 BMO Harris Bank N.A.