Please Print Clearly
*Last Name:_________________ | *First Name:___________________ | *Date of Purchase:____/____/____ |
*Mail To Address:______________________________________ | ||
*Mail To Address:______________________________________ | ||
*City:___________________ | *State:(if applicable)___________________ | *Zip/Postal Code:_______________ |
Phone Number:_________________ | Fax Number:__________________ | *Email:______________________ |
Ordering Options(please circle one):Money Order/Check/Credit Card/Credit Card already on file | ||
Credit Card Type(circle one):Visa/MasterCard/Discover/American Express | Card Number:________________________ | Expiration Date:_____________ |
Information for lines with a * next to it are required to ensure the order is smooth. | ||
If you would like to order more than one of anything, please specify in the Product Name/Description line. | ||
Number:__________________ | Product Name/Description:_____________________ | Price:________________ |
Number:__________________ | Product Name/Description:_____________________ | Price:________________ |
Number:__________________ | Product Name/Description:_____________________ | Price:________________ |
Number:__________________ | Product Name/Description:_____________________ | Price:________________ |
Number:__________________ | Product Name/Description:_____________________ | Price:________________ |
Number:__________________ | Product Name/Description:_____________________ | Price:________________ |
|
||
Shipping Cost | $5.00 flat rate | Shipping Cost_____$5.00__________ |
USPS | Days:Overnight/2-3days priority | Other:_____________________ |
I hereby certify that the information given to Kicks Hobby Japan is correct. | Signature:_____________________ |
Click Here to go back