Internet Application

★Applicant's Information
Full Name

     Alphabet
 　  Family Name* 　　   Last Name*
 　  Japanese Katakana カタカナ (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
 
Age     *The subscriber shall be elder than 20 years old.
 

 
★Property Information
  The exact address of the property which you wish to install the cable internet.
  Address*
 
  Buiding Name*
    Room Number*
  Buiding type* Condo(own)Apartment(rental)House (own)House (rental)Other
 

★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.

  Intend length of use the internet
      about years

 
★Option
  1) Rental Wi-fi router YesNo

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.