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Children's smiles to the future

ORDER FORM

Those who order by FAX or Email to thank you for your order on the fill in the following.
　・Postal code
　・Address
　・Name
　・phone number
　・Name of product
　・Payment method

*, plesase fill it.

Name*
Phonetic*
Postal code*
Address*
Phone number*
E-mail address*
When you make a mistake the e-mail address,
we can not send it your confirmation email, please check
Hope Quantity* Rice 5kg　 　10kg　
Brown Rice　5kg　　 10kg　　 30kg　
Requested delivery date  月　日
Hope delivery time  
Payment method  
 Remarks  

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