====== About our customers ======

■ Name ■

　Furigana [full-width] ■

■ Email address ■

　E-mail address (for confirmation) ■

■ Where you live ■
·Prefectures
---Select the prefecture---HokkaidoAomoriIwateMiyagiAkitaYamagata PrefectureFukushimaIbarakiTochigiGunmaSaitamaChibaTokyoKanagawa PrefectureNiigataToyamaIshikawaFukuiYamanashi PrefectureNaganoGifuShizuoka PrefectureAichiMieShigaKyotoOsakaHyogoNaraWakayamaTottoriShimane OkayamaHiroshimaYamaguchi TokushimaKagawaEhimeKochiFukuokaSagaNagasakiKumamotoOitaMiyazakiKagoshimaOkinawaetc.
・ Municipality [Full-width]

・ Address / building name [full-width]

・ Telephone number [half-width number]

■ Shipping address
* Please enter only if you wish to ship to an address other than the above.
·Prefectures
---Select the prefecture---HokkaidoAomoriIwateMiyagiAkitaYamagata PrefectureFukushimaIbarakiTochigiGunmaSaitamaChibaTokyoKanagawa PrefectureNiigataToyamaIshikawaFukuiYamanashi PrefectureNaganoGifuShizuoka PrefectureAichiMieShigaKyotoOsakaHyogoNaraWakayamaTottoriShimane OkayamaHiroshimaYamaguchi TokushimaKagawaEhimeKochiFukuokaSagaNagasakiKumamotoOitaMiyazakiKagoshimaOkinawaetc.
・ Municipality [Full-width]

・ Address / building name [full-width]

・ Telephone number [half-width number]

====== About the car ======

■ Vehicles equipped with battery clamps ■

■ Chassis number ■

====== Purchase information ======

■ Purchase time ■

■ Purchase store ■

■ Name of the person in charge of the store

■ Contact information

■ Attachment * You can attach an image file. (File size is within 1MB per sheet)