赤で書いたところが書き込むところです。subtotalの所にはオーダーフォームで書いた金額を書き込みましょう。

Quality Health, Inc.
401 Langham House
29-30 Margaret Street
London W1N 7LB
England

Fax: 44-171-580-2043
(or UK 0171-580-2043)
Email sales@qhi.co.uk
Web http://www.qhi.co.uk
Please use the Books form for books.
Total Prices (show £ $ or Euros)
 Credit Card prices must be in Euros. 
Pharmaceuticals Subtotal 
£73.22
Supplements Subtotal 　
　
Shipping Euros 11.76 £ 8.00 $12.00 £8.00
 Registered
Post add 		Euros   4.90 £ 3.00 $  5.00 £3.00
　
Grand Total 
£84.22
All goods are shipped ex. VAT
　

Please tick
method of
payment		 Cheque/money order ここにチェックを入れます。○でもなんでも良いです。  
Visa  
Mastercard  

Important: Please read and sign the agreement below.
Customer ID#

ここは前に注文した事がある人がカスタマーナンバーを書く所です。初めての方は何も書きません。
Name

Ichiro Suzuki（名前は名字も姓も初めは大文字）

Address

5-5-204　Torayama（地区名まで書く。番地名など、日本では普通後から書く事を最初に書く。）
　 ................................................
City & State Nerima−ku　Tokyo（市町村名、都道府県名の順で書く。）
Zip/Post Code

999-0001（郵便番号）
Country Japan
Telephone

＋81-3-0000-1234（市外局番の０を取って＋８１を付けて書く）

 Fax　ファックスも電話と同様に書く
E-Mail drugmania@geocities.co.jp(自分のメールアドレスを記入)
Card Number
　 　 　 　 　 　 　 　 　 　 　 　 　 　 　 　

Expiry Date
.........................

Signature
................................................
By signing here you will authorise Ruf Bureau Services to charge your credit card with the total amount of your order. The exact amount your credit card is charged in your local currency is dependant on the exchange rate on the date of charging.
The exchange rate used on this form is:
    $1 = 0.9804 Euros
    £1 = 1.4706 Euros
For the current exchange rate please visit http://www.xe.net/currency/ or call your credit card company.

Please read and sign the following statement:
I hereby declare that I am at least 18 years old, that the products I am buying are not for commercial resale and will be used under the guidance and with the consent of a physician. I hold the shipper and Quality Health, Inc. harmless from any legal action resulting from the purchase or use of the products I am about to purchase. I understand that I am responsible for complying with my country's mail importation laws and that all goods are shipped at purchaser's own risk.

Signature Ichiro Suzuki（直筆で書くこと）
Date

月、日、西暦の順で書く

９／１５／１９９９

HELP US TO HELP YOU: 

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