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Date: Company Name: Company Address: Company Phone Number: Contact Name/Title: Contact Phone Number: Contact Email: Shipping Address: Customer Information Please complete the following information and email to [email protected] or fax to 1-801-945-2387. Amex Bank of Canada Business Reward Card Request Form Available Denominations: $25, $50, $100, $200 and $500 TOTAL Minimum $2,000 order required. Please note that Reward Cards are subject to a monthly service fee of $2.50 starting the 13th month † . Order Details Gift Employee Incentive Employee Bonus Customer Rebate Other End Use (check one) X = X = X = X = X = Quantity $ Amount Denomination Funds do not expire. For use in Canada and U.S. For more information on terms and conditions, call 1-800-505-6849 or visit americanexpress.ca/gift. In order to complete this order request, further information may be required by Amex Bank of Canada. We will contact you should additional information be required. Once all required information is validated we will provide you with an invoice for your signature and payment details. To find out how we collect, use and safeguard your personal information, please visit our website at www.americanexpress.ca/privacy, or call us at 1-888-301-5312 to request a copy of our Privacy Code. Were you referred by an American Express Representative? If so, please provide their name:
