payGO($money);

CARD USER

Name and Surname

Entry Name and Surname.

Occupation

Entry Occupation.

Nationality

Entry Nationality.

Name and Surname in Capital Letter

Entry Name and Surname in Capital Letter.

Date of Birth

Entry Date of Birth.

ID Number / Passport Number

Entry ID Number / Passport Number.

Date of Issue

Entry Date of Issue.

Issue by

Entry ID Issue by.

Expiration Date

Entry Expiration Date.

Place of Birth

Entry ID Place of Birth.

Address

Entry Address.

City

Entry City.

State, Province

Entry State, Province.

CONSENT OF INTERNATIONAL CARDHOLDER

1. I agree and consent to the Bank to block saving account in order to ensure of debt payment for the use of my visa credit card.

2. I consent to the Bank to deduct from security saving account in case there is any debt occurred from using my credit card including interest rate and fees determined by the Bank and will not oppose, resist or claim any right to the Bank.

I, as an applicant for visa credit certify that, all statements contained in this application is true. If there is any damages occurred form using of card to the Bank, I agree to take responsibilities to compensate all damages and agree to accomplish according to the rule of Visa Control Center and the law of Lao PDR.

Date

Entry Date.

Name

Entry Name.

DOCUMENTS REQUIRED

ID Type

Choose file Upload the passport personal information page.

Choose file Upload the hand-held documents and personal signature photos.

Choose file Upload the front side of the photo.

Choose file Upload the back side of the photo.

Choose file Upload the ID and personal signature photo.

I agree to General Terms of Service, Card Terms and Privacy Policy.

description and guide of the function, links to help if needed.

use for posting campaign information, etc. PAYGO($money);