MIZUMA International, Inc.
Application for a Charging Account 
Print this form out and fax it in for fast, 
convenient service! Tel: (212) 268-2025 Fax: (212) 808-0596
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                         Application Form of Charge Account 
                         
                                                         DATE: __________________


        Please choose one of the below accounts. 
                 Company     Company Section     Private 
                
        Name of Company or Name of Client:
        _________________________________________________________
          Section of Department:
          _________________________________________________________
          Dept. No:
          _________________________ (If you have)
          Type of Business:
          ________________________________________________________
          Name of Senior Officer:
          _________________________________________________________
          Contact Name:
          _________________________________________________________
          Address:
           Street:
           __________________________________________
           City:
           __________________________________________
           State:
           ___________________
           Zip Code:
           _________________________
         
          Bill Attn: 
          _________________________________________________________
          Tel:
          ___________________________________________
          Ext:
          _____________________
          Fax:
          ________________________________
        
        Name of Applicant:
        ________________________________________
        Title:
        __________________________
        Tel#:
        __________________________
        e-mail Address:
        __________________________
        Signiture of Applicant
        ____________________________________________________