PRIORITY PASS APPLICATION FORM - American Express

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PRIORITY pass APPLICATION FORMTo apply for complimentary membership of PRIORITY pass for you and your Platinum Supplementary Cardmember, please complete this form and return it in the pre-paid envelope provided, along with your other completed form (s). You will then be sent your PRIORITY pass membership cards that will give each of you, plus one complimentary guest per visit, unlimited access to over 1,000 airport VIP lounges Platinum Cardmember detailsTitle: Mr Mrs Miss Ms Other First name: Surname: Delivery address: Post / Zipcode: Country: Telephone: (inc. international code) Email: Date of birth: DD MM YYYY Cardmember s name (as it appears on the Card): Platinum Card number: 37 Card expiry date: MM YYYYI instruct PRIORITY pass Ltd to charge lounge usage fees for my second and subsequent guests, when received, at the prevailing rate currently US$27/ 24 per person, per visit to my American Express Platinum Card.

priority pass application form To apply for complimentary membership of Priority Pass for you and your Platinum Supplementary Cardmember, please complete this form and return it in the pre-paid envelope provided, along with your other completed form(s).

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