CREDIT CARD DETAILS

FAX FORM

FAX : 81-3-5825-2789

To. Japan Wine Challenge 2009

Please print out and fill in this form.

For Japanese entrants ※日本国内からのご参加につきましては銀行振込のみ受付いたします。

●Entry Information

1. Company Name
2. Contact Name
3. E-mail
4. TEL
5. FAX

●Entry Fee

Please input Entry fee as number of wines.

-Example-
If you wish to enter 2 wines;

2 wines@25,000yen per wine= Total: \50,000(including 5% consumption tax)
I wish to enter: Up to 10 wines (@25000yen per wine)
wines@25,000yen per wine= Sub Total: \
I wish to enter: More than 11 wines (@20000yen per wine)
wines@20,000yen per wine= Sub Total: \
Grand Total  \

●Credit Card Details
Credit Company VISA AMERICAN EXPRESS MASTER CARD
Card Number

Expiry Date (mm/yy)

Name on Card
Billing Address
Sigunature
Date

Please print out this form.

Japan Wine Challenge
TME Bldg. 1-9-10, Higashinihonbashi, chuou-ku, Tokyo, Japan 103-0004
Tel: 813.5825.9177/Fax: 813.5825.2789