APPLICATION THROUGH FAX FOR PAYMENT BY CREDIT CARDS

Date:................................................

The Manager
Card Centre
Nepal Investment Bank Limited
Putalisadak, Kathmandu, Nepal.

Subject: Authority to process credit card transaction through Fax.

Dear Sir,

I hereby authorize following merchant to process transactions as detailed below.

Merchant Name : - Samrat Treks & Expedition Pvt. Ltd.
Merchant No :- 012000184
Account No. (NPR):- 2614800
Account No. (USD):- 012-2614800
Branch code: - 012
Name of Bank: - Nepal Investment bank Ltd.
Sift Code: - NIBLNPKT
Tel :- 00977-1-4700397/4701351
Fax:- 00977-1-470226
Merchant Address :- Thamel, Kathmandu , Nepal

Card Holder Details:

Cardholder Name :....................................................................................

Card Number :...........................................................................................

Expiry Date :.............................................................................................

CVV Number :...........................................................................................

(3 digit printed number in the signature panel of card)

Transaction Amount :..............................................(USD/INR./NRS.)

Passport Number :.................................................................................

Billing Address :......................................................................................

Contact Address :...................................................................................

Phone No :..............................................................................................

Fax No :...................................................................................................

Email ID :................................................................................................

Disclaimer:
I kindly request you to process above-mentioned transaction. I hereby agree and accept that I have fully read and agreed the terms and conditions for the purchase of goods/ services through this transaction and I hereby indemnify merchant and Nepal Investment Bank Limited for any disputes arising by virtue of this transaction. The card has been issued in my name and I am the authorized user.

Note: Copy of Passport, Copy of front and backside of card should be enclosed here with.

Sincerely,


......................................................................
Signature

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