ORDER

Inquiry

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Please send after filling in the items in the form below.

ORDER SPECIFICATION

YOUR INVOICE NUMBER[required]
PART NUMBER[required]
TOTAL AMOUNT(JPY)[required]

SHIPPING INSTRUCTION

COMPANY NAME
CUSTOMER NAME[required]
Phone[required]
FAX
E-mail[required]
SHIPPING ADDRESS[required]
COUNTRY NAME[required]
POSTAL CODE[required]

PAYMENT INFORMATION

Please choose a method of payment.[required]

PAYMENT BY CREDIT CARD

CARD TYPE
BILLING NAME
CARD NUMBER
EXPIRY DATE
MONTH / YEAR
SECURITY CARD NUMBER

(last 3 Digit at the back of the card)

PAYMENT BY WIRE TRANSFER

BILLING NAME
BANK NAME
MUFG Bank, Ltd.
BRANCH
EKODA
PHONE
+81-3-3953-4116
ADDRESS
1-74-7 ASAHIGAOKA NERIMA-KU TOKYO 176-0005 JAPAN
FOR CREDIT TO
GRUPPEM INC.
ACCOUNT NO
0910539
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