Electronic Data Ordering Form
(Form for FAX Use)

We/I hereby place the order for the electronic data listed below under the Regulation
on the Use of Electronic Data.


To: President of the Health and Welfare Statistics, Tokyo, Japan


Date: Day_________ Month _________Year____________


Name of organization, company, individual


___________________________________________________________________________________________
Address
_____________________________________________________________________________________________

______________________________________________________________________________Zip_________

Country __________________________________
Name of president/person
represent

____________________________________________________________________________________
Name who is in charge
of the order

____________________________________________________________________________________
Telephone Number

Fax Number
_____________________________________________________

______________________________________________________

E-mail Address

_____________________________________________________________________
Please fill in here, it may be used for providing errata and other
helpful information.
Membership code number
(If you are emrolled)
________________________________________





Your Order:

Name of Electronic Data
Year of Data
Number of Data Set
Remarks


_____________________________________________________
_________________
______________
___________________________________________


_____________________________________________________

_________________

_______________

__________________________________________


_____________________________________________________

_________________

________________

__________________________________________


_____________________________________________________

_________________

________________

___________________________________________


_____________________________________________________

_________________

_________________

_________________________________________


To send this order form, please use facsimile.
FAX. : 03-3584-4710, from overseas: 81-3-3584-4710

You are kindly requested to afford the charges for sending money and
shipping the electronic data files.
The amount of shipping charges will be notified after receiving the order form by fax
or e-mail.

The return will not be accepted which is due to a cause(s) mistakenly made
by you. Therefore please make sure that the electronic data you are going
to order are correctly described in the order form.


For the details:

Health and Welfare Information Development Center
Health and Welfare Statistics Association
Located at: 5-13-14, Roppongi, Minato-ku, Tokyo, Japan


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