Fax No:

Date: -

Alpine Card Service P/L
Darbar Marg
Kathmandu, NEPAL

Dear Madam/Sir

RE: Authorization for the pay by Credit Card.

I would like to pay USD/NPR …………………….. for the purchase of …………………… to M/S Stone Carving , MID No 306080 by my VISA/MASTER CARD. The necessary details for this transaction are as below:

Card Number :

Card Expiry Date :

Amount In Figure :

Amount In Words :

Identification No. (P. P. or I.D) :

Card Holder's Date of Birth :

Address (Home/Office) :

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

Thank you for your kind co-operation.

Regards,

Signature of the Cardholder : --------------------------------------

Name of the Cardholder : --------------------------------------

* Note: Please verify amount.