Please answer the following questions.

NAME:

AGE: 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90- GENDER: MALE FEMALE

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

---