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PAYMENT FORM - 6th TAHI IPv6 Interoperability  Test Event
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Fax the information below to:
	TAHI Registration
	c/o Mika Torikiri, e-side, inc.
	Fax: 81-3-3585-8162

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Participant Name:
__________________________________________________________________________

Organization Name:
__________________________________________________________________________

Registration Number:
__________________________________________________________________________


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REGISTRATION FEE: 20,000 JPY (General) ; 5,000 JPY (Student)
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CREDIT CARD INFO
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Credit Card:	[  ] VISA	[  ] MasterCard		[  ] AMEX

Cardholder's Name:
__________________________________________________________________________

Card Number:
__________________________________________________________________________

Expiry Date:		MM		YY
__________________________________________________________________________


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PLEASE DO NOT SEND CREDIT CARD INFORMATION BY E-MAIL.
YOUR NDA MUST BE SUBMITTED TO COMPLETE REGISTRATION.
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