●●●●　Order Form　●●●●

	●　Notification of a Tentative Extra Charge for EMS　●
	Notification of revision of EMS and international parcel rates and additional of tentative extra charges - our default shipping calculation is based on Forth Zone. We will refund the differences based on the actual shipping cost. Thank you for your understanding.

Please place your order using the form below.
* Please fill in the alphabet.
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	●　Customs and import duties　●
	Any customs and import duties will be charged after the parcel reaches its destination country. These charges must be paid by the recipient of the parcel. For more information please contact your local customs office for current charges before you order.

Order Item *	About packing and a content MICAL FX 2000tab.　 1 unit : 　 6,000YEN　 Shipping:　3,900YEN 2 units: 　 12,000YEN　 Shipping:　4,740YEN 3 units:　18,001YEN　 Shipping:　5,990YEN
total price	0YEN
Shipping Method *	EMS (Express Mail Service)
Payment *	Credit Card (PayPal)
Email Address *
Confirm Email Address *
Name *	※e.g.) 石本　三千也
Preferred NameIn English	※e.g.) Michiya Ishimoto
Sex	Male Female
Phone *	※e.g.) 06-6951-4668
Mobile
FAX Number
Country *	※e.g.) JAPAN
Postal Code	※e.g.) 535-0011
Address *	※e.g.) 1-1-20,imaichi,asahi-ku,Osaka,534-0011,JAPAN
Notes
Confirmation *	Please check this box after you have confirmed that all of the information is correct.

※　If a transmitting button is pushed, it will be considered that it has agreed with "Disclaimer."

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