別紙第 1 号様式 ( ) 輸入報告書 (Import Report of Medication) (To Minister of Health, Labour and Welfare) 厚生労働大臣殿 Name of Importer Importer s Signature Address of Importer / / (Year) (Month) (Date) Phone Number Fax Number e-mail @ 品名 (Name and Size of the Import Products) 数量 (Quantity) 輸入の目的 (Purpose of Import) 誓約事項 (Oath) 6 For Personal Use 10 Other Purpose ( ) The import products above are solely for the purpose of import above, not for commercial use and/or gift for others. 製造業者名及び国名 (Name of Manufacturer and Country of Origin) 輸入年月日 (Import Date / Arrival Date) / / (Year) (Month) (Date) AWB B/L 等の番号 (AWB No., B/L No. or Flight No.) 到着空港 到着港又は蔵置場所 (Arrival place ( Airport, port or Storage place )) 備考 (Note) 厚生労働省確認欄 (For Official Use) 特記事項 厚生労働省薬事監視専門官毒物劇物監視員 厚生局 印
別紙第 5 号様式 商品説明書 (Explanation of Pharmaceutical Product) (Purpose of Import : For personal use or for treatment of patients) 商品名 (Name of product) 化学名 一般的名称又は本質 (Chemical Name or Active Ingredients Name) 用 (Intended purpose) 途 1ヒアルロン酸 (Hyaluronic acid) 2ボツリヌス毒素 (Botulinum toxin) 3 痩身効果 (Slim figure, Weight Reduction) 4アスコルビン酸 (Ascorbic acid) 5 歯牙漂白剤 (Dental bleach) 6ミノキシジル (Minoxidil) 7アバスチン (Avastin, Bevacizumab) 8サリドマイド (Thalidomide) 9 不活化ポリオワクチン (Inactivated Poliovirus Vaccine) 10リドカイン (Lidocaine) 11メラトニン (Melatonin) 12ヨウ化カリウム (Potassium iodine) 13タミフル (Tamiflu, Oseltamivir) 14シルデナフィル (Sildenafil, Viagra) 15 漢方 (Kampo products) 16その他 (Other)( ) 1ガン治療 (Cancer treatment) 2 強壮剤 ED 薬 (Tonic medicine, ED medicine) 3うつ 気分障害 不眠治療 (Treatment for Depression, Anxiety Disorder, Insomnia) 4 栄養補充 (Supplement) 5 美容 (Beauty) 6 避妊 (Birth control) 7アレルギー治療 (Allergy treatment) 8 育毛 (Hair Restoration) 9ワクチン (Vaccine) 10 皮膚麻酔 (Topical anesthesia) 11 眼科治療 (Ophthalmology treatment) 12 歯科治療 (Dental treatment) 13 特定疾病治療 (Specific disease treatment) 14 震災関連 (Earthquake disaster relations) 15 動物の治療 (Animal treatment) 16その他 (Other)( ) 特定疾病 : 介護保険法施行令第 2 条に規定する疾病 ( ガンを除く ) ( Specific disease; Disease prescribed in Nursing Care Insurance Law enforcement order Article 2. (Cancer is excluded.)) 具体的な用途 ( 効能 効果 用法 ) (Efficacy, Dosage) 規 (Specifications) 格
別紙第 6 号様式 商品説明書 (Explanation of Product) (Pharmaceutical Products are excluded) 商品名 (Name of product) 化学名 一般的名称又は本質 (Chemical Name or Active Ingredients Name) 用途 ( 効能 効果 ) (Efficacy) 規 (Specifications) 格
Tokyo Fri Mar/7/2014 - Sun Mar/16/2014 Itinerary # 169885073615 Important Information All passengers traveling to the US must provide valid travel documents and details of their full US destination address for US Immigration. Proof of citizenship is required for international travel. Be sure to bring all necessary documentation (e.g. passport, visa, transit permit). To learn more, visit our Visa and Passport page. Providence (PVD) Tokyo (HND) Fri Mar/7/2014 - Sun Mar/16/2014, 1 round trip ticket CONFIRMED Delta GKDBF6 Your reservation is booked and confirmed. There is no need to call us to reconfirm this reservation. Price Summary Traveler Information Traveler 1: Adult $1,662.10 Flight $981.00 David Laidlaw Adult Delta SkyMiles 2074834371 Ticket # 0067381644717 Taxes & Fees $681.10 Expedia Booking Fee $0.00 * Seat assignments, special meals, frequent flyer point awards and special assistance requests should be confirmed directly with the airline. 03/07/2014 - Departure 2 stops Total travel time: 21 h 36 m Total: $1,662.10 All prices quoted in US dollars. Providence Detroit 2 h 8 m 605miles PVD 10:59am DTW 1:07pm Delta 4015 Operated by ENDEAVOR AIR DBA DELTA CONNECTION Economy/Coach (T) Seat 10B Confirm or change seats with the Layover: 2 h 18 m Detroit Seattle 4 h 53 m 1,927miles DTW 3:25pm SEA 5:18pm Delta 733 Economy/Coach (T) Seat 29C Confirm or change seats with the Additional Flight Services The airline may charge additional fees for checked baggage or other optional services. 332 points For Rewards members Join Expedia Rewards today Layover: 1 h 12 m Seattle Tokyo 11 h 5 m 4,775miles SEA 6:30pm HND 10:35pm
+1 day (Arrives on 03/08/2014) Delta 581 Economy/Coach (T) Seat 35G Confirm or change seats with the 03/16/2014 - Return 2 stops Total travel time: 22 h 34 m Tokyo Los Angeles 10 h 25 m 5,458miles HND 1:00am LAX 7:25pm Delta 636 Economy/Coach (X) Seat 27G Confirm or change seats with the Layover: 5 h 10 m Los Angeles Detroit 4 h 22 m 1,985miles LAX 12:35am DTW 7:57am Delta 1468 Economy/Coach (Q) Seat 38F Confirm or change seats with the Layover: 0 h 43 m Detroit Providence 1 h 54 m 605miles DTW 8:40am PVD 10:34am Delta 3863 Operated by ENDEAVOR AIR DBA DELTA CONNECTION Economy/Coach (Q) Seat 10D Confirm or change seats with the Airline Rules & Regulations We understand that sometimes plans change. We do not charge a cancel or change fee. When the airline charges such fees in accordance with its own policies, the cost will be passed on to you. Tickets are nonrefundable, nontransferable and name changes are not allowed. Please read the complete penalty rules for changes and cancellations applicable to this fare. Please read important information regarding airline liability limitations. Need help with your reservation? Visit our Customer Support page. Call us at 1-877-261-3523 For faster service, mention itinerary # 169885073615