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APPLICATION THROUGH FAX FOR PAYMENT BY CREDIT CARDS

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

The Manager
Nabil Bank Ltd.
Durbar Marg, 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 Tours & Travels Pvt. Ltd.

Account No. (NPR):- 0101011754301

Account No. (USD):- 0104211754301

Name of Bank: - Nabil Bank Limited.

Sift Code: - NARBNPKA

Tel :- 00977-1-4004700, 4004701, 4004702, 4004703

Fax:- 00977-1-4004704

Merchant Address :- Gairidhara, 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,



......................................................................
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