Merchant Enrollment
MAIL FORM
■ Facility's Name / 施設名称:
■ Category / 種別:
■ Company's Name(in case different from Facility's name)
  会社名(施設と名称が違う場合):
■ Address / 住所:

■ Tel:
■ City : Hanoi Ho Chi Minh City Others
■ Hand Phone :
■ E-Mail :
■ Person in charge / 担当者名 :
■ Date of Enrollment / 契約日 :(from)
* ie. : dd/mm/yy ・ 日/月/年(西暦)
■ HP(If available)
URL:
■ Term :
■ Note:(If you have any branches please fill them in the column below.)

確認画面表示/Confirm your Application: Yes No
確認メールの送信/Confirmation mail: Yes No