PLEASE PRINT THIS FORM, FILL UP, SIGNATURE AND SEND A FAX AT +977-(1)-4 427 324

Date:

Himalayan Bank Ltd.
Credit Card Center
Nepal.

Dear Sir,

Re : AUTHORISATION FOR THE PAYMENT BY CREDIT CARD

I would like to Pay US$ ___________ (equivalent to Nepalese Rupees Rs.__________.)

For the purchase of ___________________________________________________to: ____________________A/C No. ______________ by my VISA card.

The necessary details for this transaction are as below:

Credit card number: ________ _______ _______ _________

Expiry date: ___________

Amount: ___________

Passport Identification number:

Billing address: _______________________________________________________

____________________________________________________________________

Kindly receive the copy of my credit card (Both side) and copy of my identification (passport) along with this request letter.

Thank you for your kind co-operation

Regards,

Signature of the card holder

Name of the cardholder: _____________________________

E-mail address: ____________________________________