ORDER FORM

Shipping Address

First Name Last Name
Address
City State^Zip
Phone Fax
e-mail address

Product Number Product Name
QTY
AMOUNT
       

 

     
       


     
       
order total Shipping&
Handling
$0. - $25.00 $5.50
$25.01 - $50.00 $7.50
$50.01 - $75.00 $9.50
$75.01 - $115.00 $11.50
Over $115.01 Free !!
Sub Total  
Sales Tax : 9.5% (CA residents only)
 
Shipping & Handling (Use chart at left)
*U.S. Orders only
 
Total Payment  

CREDIT CARD

Name on Card  
Type of Card VISA / MC / Discover
Card Number  

CVV2# (3digit numberj–

  Expiration Date  
Sign  

* CVV2# is the 3 digit value printed in the signature panel following the last 4 digits of the account number.

Billing Address (if different from Shipping Addressj

First Name Last Name
Address
City State^Zip
Phone Fax
e-mail address


For Credit Card Payment, please fax this form to 650-240-1755 or mail it to:
For Non-Credit Card Payment, please mail it with Money Order to:

Fax to : 650-240-1755
Mail to : Yamamoto Kanpou U.S.A., LLC
P.O.BOX 594
San Mateo, CA 94401