Retail Credit Card Application

I&M BANK INTERNATIONAL CREDIT CARD APPLICATION FORM
Please complete all relevant sections in BLOCK letters
I wish to apply for: Visa Classic Card ●

Visa Gold Card Visa Infinite Card
Account number (optional, to be filled by I&M Bank account holders)
1. PERSONAL DETAILS
Full name First Second Last
Preferred name on card (Should be related to full name; part of the name may be abbreviated)
ID/Passport No. Nationality KRA PIN
P.O. Box Postal code City/Town
Physical address Estate Road
Occupation Marital status No. of dependants
Education level attained (post graduate/graduate/diploma/high school)
Current residence (self owned/rented/family owned/company leased/mortgage)
Email (for card statements) Mobile No. (for SMS alerts)
NEXT OF KIN DETAILS
Full name Relationship
Email address Mobile No.
2. CARD DETAILS
Amount applied for in figures
Amount applied for in words
Where would you like the card delivered? ●

Delivery by courier Branch (Branch name)
Do you wish to apply for a supplementary credit card? ● Yes No
3. EMPLOYMENT/INCOME DETAILS
(a) For salaried individuals only
Name of employer Company email address
Terms of employment (permanent/contract) If contract state expiry date

Employed from to Position held
Net income per month (Ksh)

(b) For self-employed individuals only
Name of business Nature of business(es) Physical address
Annual turnover (Ksh)
4. FINANCIAL DETAILS
Please provide details of loans/advances and other accounts held with other banks
Bank Branch Other account number (s) Loan/Advance account number(s)
1.
2.
3.
5. REFEREES (should be different from next of kin)
1. Name Relationship
2. Name Relationship
Employer’s guarantee available? ●

Yes No
6. SUPPLEMENTARY CARD
Please note that all supplementary cards will have to be operated within the overall credit limit enjoyed by the principal cardholder and the principal cardholder will be liable
for any usage of the card by the authorised user. The details under this section pertain to the supplementary cardholder who must sign as indicated under declaration section.
The supplementary cardholder must be 18 years or older.
1. Name Mobile No.
Date of birth ID/Passport No. Email address

Nationality Relationship to principal cardholder
Requested card amount KRA PIN

2. Name Mobile No.
Date of birth ID/Passport No. Email address

Nationality Relationship to principal cardholder
Requested card amount KRA PIN
7. AUTO-DEBIT INSTRUCTIONS (optional, to be filled by I&M Bank account holders)

I hereby authorise you to debit my Account No. ___________________________________________ with I&M Bank for payment of ___________________ % of the billed amount on
the respective due dates without requiring you to give me notice prior to debiting the account (applicable card minimum % applies).
8. DECLARATION
TERMS & CONDITIONS
I confirm that all the above details are correct and that I have read, understood and agree to be bound by I&M Bank General Terms and Conditions, and Credit Card
Application General Terms and Conditions as amended from time to time and available at https://www.imbankgroup.com/ke/terms-and-conditions/ . I also agree to indemnify
and hold I&M Bank Limited harmless from and against all claims arising from any information that I have provided herein.
PRIVACY NOTICE
I hereby acknowledge that I have read and understood how the information that I have provided in this form will be used by the Bank as outlined in the Privacy Notice
available at https://www.imbankgroup.com/ke/information-security/privacy-notice/ and I consent to usage of this data as stipulated therein.
Tick both to confirm acceptance

Terms & Privacy
conditions notice
Principal card applicant Signature Date
Supplementary card applicant 1 Signature Date
Supplementary card applicant 2 Signature Date
PLEASE ATTACH THE FOLLOWING DOCUMENTS

Salaried Self employed Supplementary cardholder
1. Certified copy of latest pay slip 1. Copy of registration certificate of business 1. One colour passport size photograph
2. Copy of valid work permit (if non Kenyan) 2. Copy of current operating licence 2. Copy of ID/ passport
3. Six months certified bank statements for 3. Six months certified bank statements for other bank accounts held
other bank accounts held. 4. Recent colour passport size photograph**
4. Employer's guarantee *(if available) 5. A Copy of ID/Passport**
5. Recent colour passport size photograph** 6. Loan statement where applicable
6. A copy of ID/Passport**
7. Loan statement where applicable
* Letter of guarantee from employer in format provided by the Bank

** To be provided by those who do not have an account with the Bank

Retail Credit Card Application

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Retail Credit Card Application

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I&M BANK INTERNATIONAL CREDIT CARD APPLICATION FORM

Please complete all relevant sections in BLOCK letters

I wish to apply for: Visa Classic Card ●

Account number (optional, to be filled by I&M Bank account holders)

ID/Passport No. Nationality KRA PIN

P.O. Box Postal code City/Town

Physical address Estate Road

Occupation Marital status No. of dependants

Education level attained (post graduate/graduate/diploma/high school)

Current residence (self owned/rented/family owned/company leased/mortgage)

Email (for card statements) Mobile No. (for SMS alerts)

NEXT OF KIN DETAILS

Full name Relationship

Email address Mobile No.

Amount applied for in words

Where would you like the card delivered? ●

Do you wish to apply for a supplementary credit card? ● Yes No

Terms of employment (permanent/contract) If contract state expiry date

Net income per month (Ksh)

Annual turnover (Ksh)

Email address Mobile No.

Email address Mobile No.

Employer’s guarantee available? ●

1. Name Mobile No.

Date of birth ID/Passport No. Email address

Requested card amount KRA PIN

Date of birth ID/Passport No. Email address

Requested card amount KRA PIN

7. AUTO-DEBIT INSTRUCTIONS (optional, to be filled by I&M Bank account holders)

Tick both to confirm acceptance

Principal card applicant Signature Date

Supplementary card applicant 1 Signature Date

Supplementary card applicant 2 Signature Date

PLEASE ATTACH THE FOLLOWING DOCUMENTS

* Letter of guarantee from employer in format provided by the Bank

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