CreditCard Payment Service

PLEASE INPUT SETTLEMENT INFORMATION

*IS REQUIRED

NAME *

PLEASE INPUT YOUR FULL NAME.

ZIP *

PLEASE OMIT HYPHEN "-". (NUMERIC)

CAPITAL *

PLEASE SELECT PREFECTURE.

ADDRESS *

PLEASE INPUT THE ADDRESS.

PLEASE INPUT THE NAME OF BUILDING OR APARTMENT.

TEL *

PLEASE OMIT HYPHEN "-". (NUMERIC)

EMAIL ADDRESS *

(ALPHANUMERIC)

NOTE

CARD IS AVAILABLE IF ANY OF THESE MARKS ARE ATTACHED.

AMOUNT

11,000 yen

UPCOMING SETTLEMENT AMOUNT

11,000 yen

CARDHOLDER'S NAME*

CARDHOLDER'S NAME ON THE CARD.(ALPHANUMERIC)

CARD NO*

PLEASE INPUT 14-16 DIGIT NUMBER WITHOUT HYPHEN "-" AND SPACE

EXPIRATION DATE*

PLEASE INPUT MONTH AND YEAR (MM/YYYY)

CARD CVV2 *

WHAT IS CVV2 NUMBER?

I agree about the handling of personal information.
※ Please be sure to check before proceeding to "CONFIRM".

This credit card payment system is provided by Maxconnect.
PLEASE INPUT PERSONAL INFORMATION AFTER CONFIRM PRIVACY POLICY OF OUR COMPANY.

FOR ANY INQUIRY
CREDIT CARD SUPPORT CENTER
　Tel: 03-6826-5621 (WEEKDAYS: 10:00-20:00)
INQUIRY E-MAIL ADDRESS
　payment@maxconnect.co.jp

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