| Name of Credit Card | _______________________________ |
| Card Account # | _______________________________ |
| Card Holder Name | _______________________________ |
| Expiration Date (Month/Year) | ______________ / ______________ |
| Address | _______________________________ |
| TEL (Including area code) | _______________________________ |
| Country | _______________________________ |
| Zip | _______________________________ |
| Item | Price JPY (1) | Quantity (2) | Subtotal (1)x(2) | Note |
|---|---|---|---|---|
| Total | ____________________________ | |
| * Tax | ____________________________ | ( Japan residents only ) |
| * Shipping | ____________________________ | ( Vary for weight(Kg) ) |
| Grandtotal | ____________________________ |
