CREDIT CARD PAYMENT FORMAT



Date:

 

To,

The Manager

Gurkha Encounters Pvt. Ltd.

House No.135, Chaksibari Street, Thamel,  Kathmandu, Nepal

Nepal

 

 

Re : Authority to charge to the card

 

 

Dear Sir/Madam,

 

With reference to the captioned subject, I/We, the cardholder Mr/Mrs/Ms…………………………………. of the card with following details, irrevocably authorize you to debit the below mentioned card details for an amount of NPR/……………In words…………………………) for the services mentioned herein. Further I declare that I have been given choice of payment from my home currency. I agree to pay the above total amount and accept that the choice of currency is final. I understand that this facility is provided by the bank and not the card association

                                                           

Cardholder’s Name 

:

 

Card number

:

 

Expiration date         

:

 

CVV2 (3 digit code at the back of the card)

:

 

Amount in NPR         

:

 

In Words

 

 

Services/Goods Purchased

:

 

Quantity

:

 

Address of Cardholder

:

 

Billing Currency        

:

 

                                               

I understand the terms and conditions governing this Mail Order Telephone Order (MOTO) transaction and hereby indemnify you against any financial losses and declare that this transaction has been processed with my/our authorization and that shall be binding on me without further rights on my part to further dispute the transaction.

 

Thank you.

 

 

___________________________

<<Signature of the cardholder>>

 

<<Name of the Card holder>>

 

 Encl: Copy of Passport, copy of Front and Back of the card