Privium application form

Supplementary Cardmember application *

Apply for a new Privium Partner membership

Transfer an existing Privium membership

Personal Data New Privium Partner Member

Please fill in the data of the holder of the supplementary Platinum Card in this section

Title *

Surname according to passport *

Initials *

First name ( like mentioned in passport) *

Insertion

Please be aware that if the surname that is registered at American Express does not match the name in your passport, linking your Amex account and Privium membership might not be possible. If this is the case, please contact American Express Customer Service to have the name on your card changed.

Please write your initials without blank spaces in this format: ABCD

Date of birth *

Please write your date of birth in this format: dd/mm/yyyy.

Nationality *

Other nationality *

Unfortunately, it is not possible to register for Privium with a passport from Great Britain

Preferred correspondance language *

English

Dutch

Privium membership number *

Your Privium membership number will be used to transfer your existing Privium membership to the Privium Partner membership as part of the American Express Platinum Card.

IBAN number *

Please write your IBAN without spaces, for example: NL89INGB0001234567. Your IBAN is required for a possible pro rata refund by Privium of your current Privium membership costs.

BIC/SWIFT code

If your bank is located outside the Netherlands.

Address line 1 *

Address line 2

Postal code *

City *

Province/State

Country *

Other country *

Mobile phone number *

E-mail address (please use a different email address than hotmail) *

Last 5 digits on your card *

Please use the email address that is already registered at American Express.

Personal Data Privium Plus member

Does the Platinum Basic Cardmember already have an active Privium Plus membership including Privium membership number? *

Yes

No

Please fill in the data of the main Platinum Card holder in this section

Surname according to passport *

Please be aware that if the surname that is registered at American Express does not match the name in your passport, linking your Amex account and Privium membership might not be possible. If this is the case, please contact American Express Customer Service to have the name on your card changed.

Initials Privium Plus Member *

Please write the initials without blank spaces in this format: ABCD

Insertion Privium Plus Member

Date of birth Privium Plus Member *

Please write the date of birth in this format: dd/mm/yyyy.

Postal code Privium Plus Member *

Privium membership number of privium plus member

*

Terms and Conditions

This form allows you to apply for a Privium membership as part of the American Express Platinum Card or transfer your existing Privium membership. This form is a service provided by Lyyti Oy. Lyyti Oy will share your data with American Express Europe S.A. and Schiphol Nederland B.V..

Your information will be retained by American Express as long as you are a Platinum Card holder.

The name with which you register at Privium should be the same as the name known to American Express. If this is not the case, linking your American Express account and Privium membership might not be possible. This means that the 100% discount on the Privium membership will not be valid. Your Privium Plus and/or Privium Partner membership will be continued and you will receive invoices from Privium for the membership fee(s).

If you cancel your American Express Platinum Card, the 100% discount on the Privium Plus and/or Privium Partner membership will not be applicable anymore. Your Privium membership(s) will be continued as a paid membership so you can still use the services related to the Privium membership(s). If you would like to cancel your Privium Plus and/or Privium Partner membership, you can do so by going to the Privium website.

Date of birth *