Internet Application N

LINEで送る
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★Applicant's Information
Name*

  Alphabet
  Family Name*   Last Name*
  Japanese Katakana (if possible)
  Family Name   Last Name
Email *
  1.     2.
Phone Number*
  1.     2.
Skype ID
 
LINE ID
 
Nationality
 
Language of your speak
  EnglishJapaneseOther language
Occupation
 

★Property Information
  The detailed address of the property which you desired the internet introduction.
  Address*
 
  Buiding Name*
    Room Number*

★Wishing Date for installation work for internet starting *
  What date do you prefer to install the internet into your home?
  The wishing date should be the date of after two weeks or later.

    1st choice : ( yyyy-mm-dd )
    2nd choice : ( yyyy-mm-dd )
    3rd choice : ( yyyy-mm-dd )

Intended length of use
    about years

★Service type and Option
  Please check the button of your Service type and which of your preferable option plan.     ⇒ Detailed Condition

A-1 Family type Hikari Next Hayabusa 1GbA-2 Family type Hikari Next 200MbA-3 Family type Hikari Next 100MbA-4 Family type Hikari PremiumB-1 Mansion Hikari Next Hayabusa 1GbB-2 Mansion Hikari Next 200MbB-3 Mansion Hikari Next 100MbC-1 Mansion Hikari Premium OpticalC-2 Mansion Hikari Premium VDSLC-3 Mansion Hikari Premium LAN
Plan1Plan2mini

Option
  1) Ninen Wari YesNo
  2) Wi-fi router YesNo

Other requirement

Message

Identification

Please submit one or more ID.
 PassportResidential Card (在留カード)Japanese Driver LisenceJapanese Health Insurance card
     

 

Confirmation

I have an intend to continue the contract for more than one year.
I understand the cancellation policy and I agree that I may have to pay additional cancellation penalty when I cancel the contract in most case.