□ Please print this page out and fill out required items and send by fax. □
Order Form for Custom-made Uniform
Name: Mr./ Ms.
Date
/
/
Address:
Telephone number:
 Fax number:
E-mail address:
Please fill in the blanks with your card information　(Visa/Master/JCB/Amex)
Card:
 Expiring date:
Card Number:
 Holder's name:
Material
MH-10
(No.10 canvas)
MH-11
(No. 11 canvas)
Pinack
(thin and lightweight)
#163
(heavy weight)
Height:　　　　　cm
Weight:　　　　　kg
Waist:　 　　　　cm
Embroidery
 Appointed Label(If you don't write here,we put HIROTA label)


Remarks Column
Name
Embroidery on chest
Embroidery on sleeve
Others





     
* Including shrinks for each sections(A-J)
  /  
Not including shrinks for each sections(A-J)
(Please circle which you measured)
 

Jacket Pants(normal) Pants(high waist)
A
cm
G
cm
G
cm
B
cm
H
cm
H
cm
C
cm
I
cm
I
cm
D
cm
J
cm
J
cm
E
cm
*Please measure including highwaist part(4cm)
F
cm
Fax number for order
Tokyo head office:+81-3-3730-5336