LE-BARON INTL'

LETTER OF AUTHORIZATION

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

Alpine Card Services

Credit Card Division

Authorised Representative To Standard Chartered Bank

Durbar Marg

Kathmandu, Nepal

RE: AUTHORIZATION FOR THE PAYMENT BY CREDIT CARD

Dear Sir/Madam:

 

I would like to pay US$.................... for the purchase of .................... to M/S LE-BARON, MID No 9102130630

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 license to verify the signature.

PLEASE PRINT THE FORM & FAX THIS TO:

Le-Baron Intl'

Fax: 977-1-441-9099

USA based Fax:

270 626 3853

425 944 6611

702 921 7783

UK based Fax:

0705-342-2800

Germany based Fax:

081 21 90000 7699

Canada based Fax:

615 704 2993

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