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WhiteWater Nepal - Payment by credit Card form

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

Himalayan Bank Limited
Credit Card Centre
Lalitpur, Nepal

Dear Sir,

Authorization for the Payment by credit Card

I would like to pay US$…………… for the Advance of............................................. to WhiteWater Nepal Pvt. Ltd. by VISA/MASTER card.
The necessary details for this transaction are as below:

Card Number..................................................................................................................
Expiry Date ....................................................................................................................
Amount .........................................................................................................................
Identification Number.................................................................................................
Billing Address ...........................................................................................................

Kindly receive the copy of my credit card (both-side) and the copy of my identification along with this request Letter (please fax the photocopy of credit-card both side and your passport for identification)

Thank you for your kind co-operation.
Regards,

Signature of the Cardholder.....................................................................................
Name of the Cardholder............................................................................................
Nationality of the Cardholder...................................................................................
Passport number......................................................................................................
Address (Card holders’).........................................................................................
Telephone.......................................Fax....................................................................
E-mail........................................................................................................................
Confirm me, when you receive this :- By Email or by Fax