Credit card information

Enter all the credit card details here, print the page and fax it to +81-564-55-8113

Preferred user name:
Given name(s):
Family name / Surname:

		I authorize the Yamasa Institute to deduct from my credit card the sum of
Credit card:
Credit card number:		(without spaces, hyphens etc. )
Card expiration date:

I confirm that I understand and agree to the Institute's terms of service, refund and privacy policies and have read the updates file. (please, read it here)
Date:
Signature: