Date:

To,

The American Express,

Credit Card Division,

Durbar Marg,

Kathmandu, Nepal.

Dear Madam / Sir,

RE: Authorization for the Payment by Credit Card

I would like to pay US$…….( In words US$................................................................. ) for the purchase of Air Tickets to M/S Mt. Kailash Tours and Travels P. Ltd., MID No. 982 265 236 8 by my AMEX CARD. The necessary details for this transaction are as below:

Card Number :

Card Expiry Date :

Amount in Words :

Nationality :

Date of Birth :

Passport Number :

Address (home / office) :

Tel No. (home / office) :

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

Thank you for your kind co-operation.

Regards,

Cardholder’s Signature ______________________________

Name of the Cardholder _______________________________

* Note: Please verify the amount