Card Payment Form

Date:

The Manager

Card Centre

………………………………………..

 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            :

Merchant No                 :

Merchant Address         :

Cardholder Name        :

Card Number               :                                                                      

Expiry Date                  :

CVV/CVC Number      :          

Transaction Amount    : U.S. $./ INR.₹/ Rs.

Passport Number        :

Country                       :

Billing Address             :

Contact Address          :

Phone No                    :

Mobile 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 …………………………………………………. for any disputes arising by virtue of this transaction. The card has been issued in my name and I am the authorized user.

Note: Please kindly send us Copy of Passport, Copy of front and back side of card

Sincerely,

……………………………………..

Signature