Contact Gene Liberty

SIM CARD REGISTRATION FORM

Please fill up following registration form in order to use JP Mobile Sim card.

Select Data Plan

Sim Type : Micro Sim Nano Sim

Date of Flight

Referrer Name:

Email Address:

Confirm Email Address:

Password:

Contract Type:

First Name (Japanese):

Last Name (Japanese):

First Name (English):

Name as per passport

Last Name (English):

last name as per passport

Gender : Male Female

Date of Birth:

Nationality:

Passport Number:

Post Number:

Prefecture:

Example: Ikebukoro

City:

Ban Chome:

Example: 1.2.3

Building/Room No.:

Upload:

Pipal Briskshya Marga,
New Baneshwor, Kathmandu Nepal
Tel: 9808055571/9808055572

Yubinbango170-0014 Toshima-ku, Tokyo Ikebukuro 1-7-12 TEL: 03-6912-7193
FAX: 03-6912-7195