Change of Travel Booking Provider Form

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BTA_TravelAgency_SW_Jan2014American Express Services Europe Limited, England, branch,org. no. 516402-4480 (The Swedish Companies Registrar’s Register for Foreign Branches), 106 82 Stockholm, Sweden. Registered office: Belgrave House, 76 Buckingham Palace Road, London SW1W 9AX, United Kingdom. A limited company in England and Wales with registered number at Companies House: 1833139.American Express Services Europe Limited is authorised by the Financial Conduct Authority in the United Kingdom in accordance with the Payment Services Regulations 2009 (reg. no. 415532) for the provision of payment services

AmericAn express® Business TrAvel AccounT

Please complete this form ON YOUR COMPUTER. If more than one person needs to complete this form please save the form and forward it electronically. If you cannot complete on screen you may print this form and complete in CAPITALS with black ink. All fields MUST BE completed in order for this form to be processed (unless otherwise stated). You may find it helpful to refer to your Finance Director or Company Secretary for the information requested relating to the data captured on the original application form. please complete all fields.

1. existing company Details

Company Registered Name:

Existing MCA/BCA:

Existing BTA Number :

Existing BTA name:

Existing Travel Booking Provider Name:

New Travel Booking Provider Name:

New Travel Booking Provider Address:

Postcode:

2. new Travel Booking provider Details

New Travel Booking Provider contact person name:

New Travel Booking Provider contact person Telephone number:

New Travel Booking Provider contact person email:

Have the company details captured on the original application form changed? If yes, you will need

to complete a new application form. Yes No

Have the company director/beneficial owner details captured on the original application form changed?

If yes, you will need to complete a new application form Yes No

Is a Direct Debit in place ? Yes No

Authorised signature:

✗ D D m m Y Y

By completing and submitting this application you confirm that you are authorised to provide the personal data included in this application to American Express Services Europe Limited. You acknowledge that personal data provided in the application may be processed in accordance with applicable data protection law for the purposes of administrating your participation in the American Express Business Travel Account.

Authorised Signatory Full First name and Middle name:

Authorised Signatory Last Name:

Job Title:

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