Payment Form

Please complete the following form to pay for your purchase from
OKA AUTO USA division of MIROX Corporation.

* = Required Fields

Company Name:

* Name: (First Last)

* E-mail Address:

Web Site:

* Address:

Address2:

* City:

* State or Province:
US and Canada

Outside US and Canada

* Country:

* ZIP or Postal Code:

* Phone:

* Payment Type:

* Account Number and Expiration (Month/Year) and Security Code
(3 or 4 numbers).
Input format:
NNNN NNNN NNNN NNNN X MM/YY - NNN(N)

Any additional information you wish to provide:

Your payment will be processed through our Merchant Account.
Your Credit Card Statement will show "MIROX Corporation - Las Vegas".

Accepted Payments:

American Express DISCOVER Master Card VISA
Credit Cards
are accepted on all direct orders.