Date:

To: Marketing & Sales Dept.
Mitsubishi Chemical Techno-Research Corporation

Fax: +81-3-5226-0741
4F Kojimachi-Tokyu Bldg., 6-6 Kojimachi, Chiyoda-ku, Tokyo 102-0083, Japan

Send me the report entitled "Environmental endocrine disrupters" according to the following instructions (please type or print):

Name: .................................................................................................................................................................................................

Title and department: ..............................................................................................................................................................

Company/organization: ..........................................................................................................................................................

Address: ............................................................................................................................................................................................

Telephone: ..................................................................................

Facsimile: ...................................................................................

E-mail: ...........................................................................................

Number of copies: ................................................................

Amount in Price: JPY38,000.-
   (not including consumption tax in Japan and shipping charge to overseas addresses):

JPY38,000.-

(for 1 copy)

Method of payment:

Bill me

Signature:........................................................................................................................................