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First Name

Middle Name

Last Name


Mobile Number

Do you have any other credit cards?


Net Monthly Income

Please enter your monthly salary as per your payslip excluding bonus, incentives, cash and in-kind components

Resident Address 1 ( H. No., Floor No... etc)

Resident Address 2 ( Street , Near by... etc)

Resident Address 3 ( Street , Near by... etc)

  1. To verify the information in the pre-qualification form with credit bureaus including CIBIL. I am aware that the request may impact my credit score.
  2. To be contacted on the email and mobile number shared by me, even if I am registered with the National Customer Preference Register (NCPR) and opted out of receiving all promotional calls and messages. I understand that my personal and sensitive information shall be used and shared by AEBC in accordance with its Privacy Policy as updated on the website. For details of Privacy Principles please log on to
*Card fees will be reimbursed as per American Express guidelines. To know more, please click here

Congratulations !

You are pre-qualified for a Personal Card membership from American Express®

Our sales representative will get in touch with you within 1 business day to complete the application process. You may also call us on 1800-3000-2639 to set up an appointment.

Thank you for your interest