Japanese Ant Database CD-ROM Order Form
INTERNATIONAL FAX
To: Mr. Eiichi Iwaki
IDENGAKU-FUKYUKAI
FAX:+81-559-72-9080
Date:
I wish to order ______ copy(ies) of the Japanese Ant Database CD-ROM,
and authorise payment of __________ Japanese yen by Visa or Mastercard.
Name of Cardholder ______________________________ (print)
Type of card: ( ) Visa, ( ) Mastercard
Card No. ____________________________
Expiry Date _____/_____
Cardholder's Signature ________________________________
Tel : ____________________________
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DELIVERY ADDRESS
Name : _______________________________
Address: ____________________________________________
_____________________________________________
_____________________________________________
Country: ________________________
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MESSAGE IF ANY:
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