傳真:_____________________傳真:_____________________
開戶銀行:_________________開戶銀行:_________________
帳號:_____________________帳號:_____________________
郵政編碼:_________________郵政編碼:_________________
_________年________月____日_________年________月____日
簽訂地點:_________________簽訂地點:_________________