AUTHORIZATION LETTER

                                       (attachment copies of 2 sides of the card)

 

 

My name : .......................................................... Nationality : ......................................................

Passport number : ........................... Date of issue : ...................... Date of expiry : .....................

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

Tel : .................................................................... Fax :...................................................................

 

Hereby authorize the following company.

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

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

Tel : .................................................................... Fax :...................................................................

to withdraw the amount of $US ..................(in letters .................................................................

..................................only) from my personal bank account by using my Credit Card .

 

Card number : ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ ÿÿÿÿ

SBJ code :  ÿÿÿ     VISA ÿ  MASTER ÿ    Expiry date

 

This amount is the payment for the following services.

 

No.	Description	Amount

 

Client’s signature sample

 

Signature of the card holder	Signature of the card holder	Signature of the card holder