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ORDER FORM
All the proceeds from the sales of this book are donated by Mrs. Tomiko Nakayama, President, Hakusui Trading Co., Ltd., Osaka, to the Pierre Fauchard Academy Foundation Mitch Nakayama Memorial Fund, of the international dental educational organization for elevation of dental arts and science.
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BRIEF EARLY HISTORY of the PFA JAPANESE SECTION
To order, please complete this form and send to:
DR. GEORGE J. HIGUE, TREASURER
PIERRE FAUCHARD ACADEMY FOUNDATION
3351 Bounty Circle, Huntington Harbor
Huntington Beach, California 92649
U. S. A.
Phone-FAX: 1-318-592-2635
Or to:
PIERRE FAUCHARD ACADEMY FOUNDATION
c/o Mrs. Tomiko Nakayama, President,
Hakusui Trading Co., Ltd.
1-15, 1-chome Niitaka, Yodogawa-ku Osaka 532,
Japan
Phone: 06-396-4455, FAX: 06-396-4457
Please pay in advance (international Money Order or Credit Card)
in the amount of US$40.00 per book, that includes the shipping and mailing costs.
Please do not send cash nor personal check.
Quantity of Order: ____________________________
Amount of Order : US$ ________________________
Orderer: _________________________________________________________
...................DR. Mr. Mrs. Miss. Ms.
SHIP TO:_________________________________________________________
Mailing Address___________________________________________________
City___________________________State_____________Zip Code__________
Country_____________________________
Your Daytime Phone Number:________________________________________
FAX Number:______________________________________________________
Payment Amount Enclosed
International Money Order: USD $ __________________
Credit cards accepted only when ordering from Japanese distributor:
__Visa___Mastercard
Credit card #:________________________________________________
Expiration Date:______________________________________________
Print name:__________________________________________________
Your signature:_______________________________________________
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