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[ 日本語 ] Aptiva Summer

1. Print this form using the FILE / PRINT option on the toolbar
2. Fax to: 03-5561-9545 - Internet Access Center K.K. to activate your account.

Date:____/____/19___

Name: Mr./Ms._______________________________________ Please print clearly

Address: ____________________________________________

____________________________________________________

____________________________________________________

________________________________Post Code____________

Daytime Tel: _(___)___________ Fax:_(___)_____________

Type of Account:________________________________________(Please refer to brochure)

Credit Card Information : AMEX / MASTERCARD / VISA

Card No: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiration Date: ___/19___ Signature: ___________________