PRIORITY PASS APPLICATION FORM - American Express

1 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.

2 I agree to abide by the conditions of use as outlined at of Main Platinum Cardmember* Date: DD MM YYYY If you hold an International Euro Currency Card LXPCCEH3 BIEN (for internal use only) If you hold an International Dollar Currency Card LXPCCEH3 BIDN (for internal use only)Please tick the relevant box for charging guest visits:Platinum Supplementary Cardmember detailsTitle: Mr Mrs Miss Ms Other First name: Surname: Date of birth: DD MM YYYY Cardmember s name (as it appears on the Card):Platinum Supplementary 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.

3 I agree to abide by the conditions of use as outlined at of Platinum Supplementary Cardmember* Date: DD MM YYYY If you hold an International Euro Currency Card LXPCCEH3 SIEN (for internal use only) If you hold an International Dollar Currency Card LXPCCEH3 SIDN (for internal use only)Please tick the relevant box for charging guest visits:*In order to provide this service, American Express Services Europe Limited needs to share the information you have provided with PRIORITY pass . We will also share your date of birth with PRIORITY pass for ongoing identification and account validation purposes. PRIORITY pass will use the information solely for the purpose of providing their services, and will not share it with any third parties.

4 These conditions are also available in full at we have completed your lounge access enrolment, PRIORITY pass will send you your PRIORITY pass cards and worldwide lounge listing, which you should receive within 28 days. Your Platinum Supplementary Cardmember s PRIORITY pass card will be sent to the address detailed 7486H 01/17 American Express Services Europe Limited has its registered office at Belgrave House, 76 Buckingham Palace Road, London, SW1W 9AX, United Kingdom. It is registered in England and Wales with Company Number 1833139 and is authorised and regulated by the Financial Conduct Authority. Where American Express Services Europe Limited Cards are issued in the UK but obtained within the European Economic Area, local rules may apply to the way that it conducts its business which can be enforced by that country s applicable regulatory authority.

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