Please answer the following questions.
NAME:

AGE: GENDER:

E-MAIL adress: @

Input it again for the confirmation.
 E-MAIL adress:

STREET ADRESS:

City:

State:

Country:

Zip Code:

Telphone number:

Fax number:

* May I connect with you by fax in case of your email address does not work by any reason?

Yes. No.

* Have you ever purchaced a NAKAYA pen?

Yes. No.


* Plese select the seal model.
 Go to sample.

 (A) Round Seal (13.5mm 0.53inch), Natural box tree $100
(B) Round Seal (13.5mm 0.53inch), Black water buffalo $200
(C) Round Seal (13.5mm 0.53inch), Genuine ivory $400
(D) Square Seal, Natural box tree (21 sq.mm 0.83 sq. inch) $200
(E) Square Seal, Natural box tree (24 sq.mm 0.94 sq. inch) $220
(F) Square Seal, Black water buffalo (21 sq.mm 0.83 sq. inch) $280
(G) Square Seal, Black water buffalo (24 sq.mm 0.94 sq. inch) $300
(H) Square Seal, Stone (15 sq.mm) $151
(I) Square Seal, Stone (12mm*20mm) $170


* Please choose a "writing style".

- For "Round Seal"-(A) - (C)

INSOU KOIN KAISHO TENSHO GYOSHO

 - For "Square Seal"- (D) - (G)


INSO TENSHO

* Please choose a "Leather case".(FREE) - Only "Round Seal"(A) - (C)
 black red

- About Japanese kanji characters -
If you already have a Japanese kanji characters, please let us know
by fax (3-3833-1372) or JPG data.
If not, please let us know the meaning of your first or family name.
If you are unsure of the meaning of your name or would like a differentcharacter,
we will use a character based on the phonetic sound of your name..



- Delivery time -

 About 2 weeks


* Method of payment;
 bank transfer credit card

For credit cards please proceed to the authentication procedure on the next page after sending this form.

* Additional comments or questions.

* Finally, How did you learn of NAKAYA's site?
 Yahoo! Lycos The other search engines
The other homepage
-Not from a web site-
 A friend Other


After confirming the above information, click SEND.



If you do not receive a reply from NAKAYA within 48 hours,
please let us know directly by e-mail nakaya@platinum-pen.co.jp.