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 to apply for a subscription, back issue or reprint.  We also accept bank transfers in dollars or Japanese yen (contact us for instructions), but will only invoice for amounts of $700 or more accompanied by a purchase order.  PLEASE PRINT.

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ORDERING INFORMATION

____ SUBCRIBE: Yes, we want to succeed in Japan.  Send us ____ one-year subscriptions to SUCCESS STORIES: JAPAN for the executive subscription price of US$545 or JPY 54,500 each (US$595 outside the USA), a 31% savings from the US$795 regular price.  Or for US$495 if I'm affiliated with an educational or non-profit institution.

____ BACK ISSUES: I'd like to order ____ copies of the _________ issue of SUCCESS STORIES: JAPAN.  If I'm a subscriber, I agree to pay US$59 per copy, or US$29 per copy if affiliated with an educational or non-profit institution.  If I'm not a subscriber, I agree to pay US$199, or US$99 if affiliated with an educational or non-profit institution (and the $199/$99 can be credited towards the full subscription price if I subscribe within 30 days).  In all cases, a 10% discount applies to all orders of 3 or more back issues ordered at the same time.

____ REPRINTS: I'd like to order ____ copies of the _________ issue of SUCCESS STORIES: JAPAN that profiled our company.  I understand that the minimum order is US$750 for 100 copies, and US$2 for each additional copy.

PAYMENT INFORMATION

____ Enclosed please find my check or money order (payable to Success Stories Media, Inc.) 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 this form to (212) 579-3785 in the USA, then send an e-mail to Japan@SuccessStories.com to confirm we've received the fax.