Fax Order Form |
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Please Fax to: +81-42-848-5148 |
Please print out this form, fill it in completely and fax us at: +81-42-848-5148
We will contact you shortly to confirm your order. |
PRODUCT(S) |
Product Number | Product Name | Qty | Amount | |||
_______________ | ___________________________________________ | ______ | US$___________ | |||
_______________ | ___________________________________________ | ______ | US$___________ | |||
_______________ | ___________________________________________ | ______ | US$___________ |
Shipment: FREE Shipping |
PAYMENT METHOD |
VISA___ | MASTER___ | AMEX___ | PayPal___ |
CREDIT CARD INFORMATION (when pay by Credit Card) |
Name as it appears on credit card: _______________________________________________________ | |
Card Number: | |
Expiration Date: ____________________________________________________________ (mmyy) | |
3/4 digit security code: ____________________________________________________________ | |
Signature: ____________________________________________________________ |
PAYPAL ACCOUNT (E-mail address) (when pay by PayPal) | __________________________________ |
BILLING ADDRESS (address to which your credit card bill is sent) |
Name: Mr. / Ms. ____________________________________________________________ | |
Company: _________________________________________________________________ | |
Address: _________________________________________________________________ | |
Phone: ___________________________ FAX: ___________________________ | |
DELIVERY ADDRESS (if different) |
Name: Mr. / Ms. ____________________________________________________________ | |
Company: _________________________________________________________________ | |
Address: _________________________________________________________________ | |
Phone: ___________________________ FAX: ___________________________ | |
BANK ACCOUNT INFORMATION |
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Ion Trading by Universal Plan Co., Ltd. |