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My name : .......................................................... Nationality : ......................................................
Passport number : ........................... Date of issue : ...................... Date of expiry : .....................
Address : ........................................................................................................................................
Tel : .................................................................... Fax :...................................................................
Hereby authorize the following company.
Name : HUONG VIET JOIN-STOCK COMPANY
Address : 20 Nguyen Truong To; Ba Dinh; Hanoi - VIETNAM
Tel : Tel: (84 4) 7162149 / 8294994; Fax :. (84 4) 7161738
to withdraw the amount of $US ..................(in letters .................................................................
..................................only) from my personal bank account by using my Credit Card .
Card number : (((( (((( (((( ((((
CVC code : ((( VISA ( MASTER ( Expiry date
This amount is the payment for the following services.
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