ࡱ > _ bjbj,E,E 44 N/ N/ 6 6 ~ ~ ~ ~ ~ D D $ n F ~ ~ ~ ~ ~ ] 0 8 ~ 6 D : Credit Card Number: ___________________________________________ Expiration Month/Year: _________ Issuing Bank/Phone No. : _______________________________________ Security Code: ________________ (You will find the above information at the back of your card) ( Three digit at the back of your card ) Name of Passenger(s) Relation ( with card holder ) DOB Passport No. Passport Expiry Authorized charge amount in US $: _______________________ Confirmation Signature: ____________ Please Read Carefully I, ________________________________________(Name of credit card holder as printed on the credit card) hereby authorize Aero Nepal Travel, Inc. to charge the above-mentioned amount to my credit card for the purpose of purchasing airfare for the passengers identified above. Service fee will be charged in case of date change, refund and cancellation. I hereby promise not to dispute or contest these charges once credit is approved. Credit Card Holder's Details Name : _____________________________________ Address : _______________________ Apt : _______ City : _______________________ Zip Code :______ X_____________________________ (Credit Card holder's authorized signature)Home Phone : ___________________________ Date : ____________________________ Cell Phone: _____________________________ Email : _________________________________ Drivers License No: ______________________ Issued in : ________________________ Please fax this form @ 1.703.348.6444 Please attach a photocopy of the credit card (front & back) and a photocopy of the card holder's driver's license. _______________________________________________________________________________________ 5512 Talon Ct, Fairfax, VA 22032 Tel : 1.703.663.8070 email : fly@aeronepal.com ! 4 6 > A O [ ] ^ c e j Ƕ~Ƕm~m h_ 5CJ OJ QJ \^J aJ hX2 CJ OJ QJ ^J aJ h_ CJ OJ QJ ^J aJ hc CJ OJ QJ ^J aJ h+8 CJ OJ QJ ^J aJ h+8 hwS CJ OJ QJ ^J aJ &h+8 hwS 5CJ OJ QJ \^J aJ hN j hz hf UmH nH u h