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Privacy World
502 Hotta-kata,
3-6-10 Hirusaido,
Kagurazaka,
Shinjyuku-ku,
Tokyo 162-0825
JAPAN

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PrivacyWorld Credit / Debit Card Order Form

Please fill out your name and address as it appears on your credit card statement. After completing the below form and clicking ORDER, you will be automatically taken to our merchant centre for card processing.
First Name:
Last Name:
Address:
Zip Code:
City:
State:
Other State:
Country:
Telephone:
Email: Do not use an AOL e-mail address as AOL rejects our e-mails.
Currency:

Product Name:	Price:





5% Credit Card Surcharge for all credit card orders.
Shipping and handling (if any):
Total Order:

If Ordering Mail Drop
Name of Country:
Price:
Name's to Receive Mail In
Name and Address to Forward Mail To:
E-mail Contact:
Code or pin number to authenticate changes at your mail drop:

Billing Information
Credit Card Type:
Name on Card:
Credit Card Number
Expiration Date: (Month-Year)
CVV2	Help

Shipping Information
Same as billing address.
Full Name:
Address:
City:
State:
Other State:
Zip Code:
Phone:
Country:
	To stop SPAM robots, please enter the 6 digit security code in the box below and remember the 6 digit code is case sensitive.
Security Code:

Comments/Questions/Feedback

Terms & Conditions
I have read and agree to the Terms & Conditions, by clicking the submit button your order is sent automatically via our SSL Secure Order Form.

Effective immediately: a 5% surcharge for credit card orders is automatically to your order..
Thank you.