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1. Date
Date: Month: Year:
2. Desired Form of Transaction (See 2 of "Sales System")
 Choose your desired form of transaction. If you are already an "Individual Special Agent " or a "Territory Agent", please click on that box.
    
Customer Purchasing rate 100% (No quota)
Individual Special Agent Purchasing rate 80% (Quota of $100 or more per month calculated at list price)
Territory Agent Purchasing rate 60% (Quota of $1,000 or more per month calculated at list price)
    (Note) People wishing to change their form of transaction, please write here:
    I wish to change from to .

  Repeat order or First order?
    First order  Repeat order

 Customer's number
    (If you have one)
3. Order (See 1 & 4 of "Sales System") (Note:5% sales tax,shipping and insurance also apply)
Hoju Tamogitake (100% genuine Tamogitake Mushrooms)
180 pills 54g (Retail price $75) X purchasing rate X units
Powder 50g (Retail price $45) X purchasing rate X units
Powder 20g (Retail price $20) X purchasing rate X units
Powder 150g (Retail price $125) X purchasing rate X units
4. Customer (Actual person)
Name :
First name
Middle name
 Last name
Sex :
Address : Street, Apartment no. :
 City :
State :
Zip :
 Country :
Telephone :
Day
 Evening 
(In order to expedite your order, your telephone number is required. Start from your area code.)
E-mail :
Fax :
5. Space for Messages

If you please, let us know in detail what is your illness and your physical condition. We will make suggestions on how to take Hoju Tamogitake. Also, let us know what has happened to you since you began taking it . Feel free to write anything.

    
6. Space for Introduced Persons

 (Please write when you have someone to introduce you. Write in as much detail as possible.)


  A. I have been introduced by the person below.
  B I want to introduce the person below.
Name :
First name
Middle name
 Last name
Sex :
Address : Street, Apartment no. :
 City :
State :
Zip :
 Country :
Telephone :
Day
 Evening 
(In order to expedite your order, your telephone number is required. Start from your area code.)
E-mail :
Fax :
When introducing two or more people, please write the information the same way as above.
7. Payment Method
1.Credit Card:
VISA MasterCard®		 (Individual Special Agents and Territory Agents are limited to credit card payments.)
Credit Card:
Card Number:
Expiration Date : Month Year
Name:
(Signature required for Fax order)
2. Bank Transfer
       Payment		 Please pay when you order. We ship after we have received your payment. We will inform you in advance of the total on-line.
Transfer fees are the responsibility of the customer.
For bank transfer information , please refer to "6. Payment Method" of "Sales System".