Just print out this form, complete it, and send or fax it to the address below together with the appropriate payment or credit card information.  We require payment with your order.  PLEASE PRINT.

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ORDERING INFORMATION

Yes, send me _____ copies of THE SUCCESS STORIES: JAPAN 2004 TOKYO GOLF COURSE DIRECTORY for the price of US$45.95 plus US$4.00 postage (US$7.00 postage outside the USA), a 35% savings from the US$69.95 regular price.  My check payable to "Success Stories Media, Inc." is enclosed, or my credit card information appears below.  For bulk orders of 3 copies or more, save money with our special bulk prices.

PAYMENT INFORMATION

____ Enclosed please find my check or money order in the amount of $__________.

____ Please bill my credit card for $___________:    Mastercard   Visa   (Circle One)

Name as it appears on card:__________________________Expiration:___________

Credit card number:________________________________ Signature:_____________________

Mr. Mrs. Miss (Circle One)   NAME:__________________________________________

TITLE:______________________________COMPANY:__________________________

ADDRESS:______________________________________________________________

CITY:_________________________STATE/PROVINCE:_____________POSTCODE:________________

TELEPHONE:______________________________FAX:_________________________

E-MAIL:__________________________COUNTRY:____________________________

HOW DID YOU HEAR ABOUT US? _________________________________________

SUCCESS STORIES MEDIA, INC.

163 Amsterdam Avenue, Suite 222

New York, NY 10023 USA

Fax: (212) 579-3785

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