Biu mu 05/HTCN03

NGN HNG TMCP U T V PHT TRIN VIT NAM

Joint Stock Commercial Bank for Investment and Development of Vietnam

NGH X L CHNH LCH CA N V CHP NHN TH

Knh gi: Ngn hng TMCP u t v Pht trin Vit Nam, Chi nhnh Sng Hn

I. PHN DNH CHO KHCH HNG:

1. Thng tin VCNT

Tn n v chp nhn th (VCNT): ......................................................

M VCNT: <m Merchant ID 56500 in trn bill>

2. Ni dung ngh x l chnh lch (nh du vo ni dung thch hp)

ngh hon tr s tin giao dch cho Ch th. L do (ch th tr hng/giao dch khng thnh cng, khng in
c ha n nhng ti khon ca VCNT vn c ghi c/ch th thanh ton bng hnh thc khc....):
.

ngh xc nhn gii ta hn mc giao dch/hy chun chi. L do: (giao dch khng thnh cng, VCNT
khng c thanh ton nhng ch th thng bo vn b tm gi hn mc.).

L do ngh x l chnh lch khc:. ...................................................................................................

THNG TIN V CC GIAO DCH

S tin ngh M chun

Ngy giao S tin giao Loi giao
TT S th M thit b hon tr/gii ta chi giao
dch dch dch
hn mc dch

<trn <trn bill> <m <6 k t <Sale/

bill> Terminal ID trn bill>
56500 in t cc/
trn bill> MOTO>

4. Chng t cung cp gi km (nh du vo ni dung thch hp)

Ho n thanh ton th

Ho n tng kt l

Ha n bn hng

Loi khc, bao gm :............................................................................................................................

Chng ti khng nh cc thng tin khai bo v h s chng minh trong bn ngh ny l chnh xc v hon
ton chu trch nhim trc php lut v chu cc ri ro c th pht sinh cng nh cc khon ph nu sai st thuc v
chng ti. ngh Ngn hng TMCP u t v Pht trin Vit Nam lin h vi cc n v lin quan x l giao
dch.
I DIN N V ...., ngy . thng nm..

(K tn v ng du)