Muktinath Tour

APPLICATION THROUGH FAX FOR PAYMENT BY CREDIT (VISA) CARDS

Date:……………………


The Manager
Card Centre
Nepal Investment Bank Limited
Putalisadak, Kathmandu

Subject: Authority to process credit card (VISA) transaction through Fax.

Dear Sir,

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

Merchant Name: TIRUPATI HOLIDAYS TOURS & TRAVELS P. LTD.

Merchant No: 012000179

Merchant Address: Kamalpokhari, Kathmandu , Nepal

Card Holder Details.

Card holder 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