APPLICATION FOR OPENING PAYMENT CARD ACCOUNT AND RECEIVING OF THE PAYMENT CARD Valid from: 01.07.2017 Customer information 1 Name * Surname * Personal identity number * Resident Non-resident Name, Surname on the Card * Address of residence of the Cardholder (street, building, apart. No., city, country, postcode) * Telephone No. * E-mail * Password (will be used for identi cation of the Cardholder) (alphabetical and/or numerical combination) * Information on the payment card and account currency 2 MasterCard Standard MasterCard Gold Maestro With printing1 Without printing 2only for the Cardholders of MasterCard Standard, MasterCard Gold, VISA Classic and VISA PlatinumBased on the assessment of the credit collateral o ered by the Client and/or solvency of the Client, the Bank will take a decision on granting credit limit and issuance of the card. The Bank has the right to refuse to issue credit card and to grant credit limit to the Client, and maintains its rights not to provide information on reasons for refusal. Information about financial collateral 3 Funds on the current account Account No. Funds on the term - deposit account Account No. In case of granting a credit, the funds, deposited on the current/term - deposit account in theAmount Currency shouldbe regarded as collateral for securing my liabilities and the said funds should be blocked till full coverage of my liabilities, in accordance with the Terms and Conditions for Issuing and Servicing of the Bank Payment Card. Guarantee Pledge I assignGuarantee contract No. concluded between the Bank and the Guarantor Guarantor’s account No. Information about the employment and financial situation 4 Business person Student Employee Pensioner Housekeeper Unemployed person Self-employed person other Information about the work placeName of the company Address of the company Town / city, country Postal code Telephone No. at work Fax Position I am in this position since Information about financesYour monthly salary (netto) Currency Other average monthly income (amount) * Currency * Average monthly expenditures (amount) * Currency * Your propertyReal estate Address Approximate value: (USD / EUR) Is your property in pawn? Yes No Other information related to issuance of the card 5 I would like to receive the Card: * At the Bank Via post Sent by courier3 Please, specify the address * Card statement to be received: At the Bank Via post By means of the Internet banking system Address for receipt of the statement I would like to receive Travel Insurance4 Standart level Gold level Silver level Platinum level 3the courier expenses shall be covered by the recipient 4for additional payment Confirmation 6 By signing this I, do hereby acknowledge, that I have read the General Business terms and conditions of AS "Industra Bank", Price-list of services, fully understand them and agree to observe the requirements; I am aware of the fact that the Bank shall be obligated to provide information to the Credit Register of the Bank of Latvia and shall be entitled to receive information from the Credit Register of the Bank of Latvia, in the events prescribed by its regulations (www.bank.lv); I assume full nancial responsibility for the Users of additional card; I con rm the completeness and accuracy of the information provided in this application, and undertake to notify the Bank on any changes related to the information indicated in this application; I agree to the processing of my personal data, including data transfer to the third parties according to the procedures specifed in the General Business Terms and Conditions; I agree to receive all kind of commercial information by e-mail and phone: Yes No Please open the payment Card account with the Bank and issue the payment Card.Klients (vārds, uzvārds) * (Name, Surname)(Signature)(Date) I hereby consent to the processing of personal data. * mandatory fields Apply