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Fucoidan AF Premium (
Capsule type) The fax exclusive application form

Please print below, enter each item and send to free fax  0120-858-456 or (+81) 925927755.
We'll return and send a confirmation mail. * Please be sure to enter the fax number in the person who doesn't have a mail address.

The name of the subscriber                     Telephone number                
The fax number               
The address
E-mail                   @
<Only when a destination is different from a subscriber, please also enter in the following.>
The name of the destination                      Telephone number
The address
●Goods and the number (The following is the price including the consumption tax)
Trial set
3 capsules set 2,730 yen
※1 set (3 drops) as far as for the family group
Capsule 1 box(90 capsules) box 55,400 yen
Set of 3 boxes (270 capsules) set 157,900 yen
Set of 6 boxes (540 capsules) set 300,000 yen
Set of 12 boxes (1080 capsules) set 570,000 yen
Special set
(2 bottles of 900ml & 90 capsules)
set 110,850 yen
Capsule fixed period course
1 box(90 capsules) box 50,600 yen
Set of 3 boxes (270 capsules) set 143,790 yen
Set of 6 boxes (540 capsules) set 272,170 yen
Set of 12 boxes (1080 capsules) set 515,230 yen
 Special set
fixed period course
(2 bottles of 900ml & 90 capsules)
set 102,060 yen
In a Fixed period course,deliver it.
Every(   )days 
          
●Method of payment (Please put a circle on the number)
1 Collection on delivery (only in Japan)
2 Mitsubishi UFJ Bank Fukuoka branch office(652)
ordinary deposit 1934685  Name:LOHAS Co
3 Credit card (handling charge no charge)
<Please enter below in only the person who chose a credit card>
The card kind [VISA・Master・Diners] 
The card number
[                             ]
The expiration date [year    month     ]
Name of the credit card[               ]
The payment number of times
[1・2・3・5・6・10・12・15・18・20・24 times・Revolving ]
When choosing transfer, it'll be shipping off after we'll confirm the transfer.
Additionally if there are a question and a delivery request date, please fill it out any time.












●Delivery request time (only in Japan)
 1  The morning     4 16:00〜18:00
 2 12:00〜14:00    5 18:00〜20:00
 3 14:00〜16:00    6 20:00〜21:00
If you fill it out, please send to free fax 0120-858-456 or (+81) 925927755.
Thank you very much for your order. We'll return and do the confirmation you ordered in a mail or the telephone.