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

Alpine Travel Service
Credit Card Division
Authorised Representative To Standard Chartered Bank
Durbar Marg
Kathmandu,
Nepal

Dear Sir/Madam:

RE: AUTHORIZATION FOR THE PAYMENT BY CREDIT CARD

I would like to pay US$..........................for the purchase of..................................... ................ to
M/S LE-BARON, MID No 305246 by my VISA / MASTERCARD. The necessary details for this transaction are as below:

Card Number:

Card Expiry Date:

Amount In Words:

Identification No. (Passport or ID):

Card Member's Date Of Birth:

Address (home/office):

 

Tel / Fax:

Thank you for your kind co-operation.

Regards,

Signature of the cardholder.............................

Name of the cardholder.....................................

 

PLEASE DELIVER MY GOODS TO
(Leave blank if address same as above)

Name:..................................

Address:.................................

Country:.................................

Tel:........................................

Fax:........................................

Note:
All fields are required and order amount above $240 requires copy of passport or driver's licence to verify the signature.

Due to security reasons we do not accept the Credit Card Information
over the web.

PLEASE PRINT THE FORM & FAX THIS TO:

Le-Baron Intl'
Fax: 977-1-441-9099

USA based Fax:
805-456-0274
530-732-9259
707-281-0266
562-268-8739

UK based Fax: (0870)-132-0093

Germany based Fax: 081 21 90000 7699

Canada based Fax: 615 704 2993

 

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