FAX : +81-3-3263-7077

XXI ICPEAC Credit Card Form

Name:

__________________________________________________________________

family

given

middle

Phone:______________________________________________

Fax:________________________________________________

E-mail:_____________________________________________

Date of Application:

__________________________

day

month

year

__ AMEX __ VISA __ MasterCard __ Diners Club

Card No:_________________________________________

Expiration Date:___________________________________

Card holder's Name (in Block Letters) :

________________________________________________

Charge ________________________ yen to my credit card

Signature :_______________________________________


For security reasons, DO NOT send your credit card information by E-MAIL. Thank you.
Registration Office of XXI ICPEAC
c/o International Communications Specialists, Inc.
Sabo Kaikan-bekkan, 2-7-4 Hirakawa-cho
Chiyoda-ku, Tokyo 102-8646, Japan
Phone : +81-3-3263-6474 / Fax : +81-3-3263-7077
E-Mail icpeac@ics-inc.co.jp