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Assessment application

Online Assessment Form

Complete this form.

Company Name*
Your Name*
E-mail Address*
E-mail Address(Retype)*
Zip Code ( ex:999-9999 )
Address1*
Address2
Telephone* ( ex:03-9999-9999 )
Fax ( ex:03-9999-9999 )
Mobile phone

Please input applied merchandise information.

Equipment type*   
Brand*
Model*
Serial №umber
Purchase Condition
Purchase Year Month     
Asking Price  JPY
Accessory(Option) (500characters)
Condition (500characters)

Please input information on the machine parts carrying out.

If different than above address
Company Name
Telephone
Inquiry*
(1000characters)