| Street | 18 Chome-2-13 Nishi 11 Jominami | ||
| City/Town | 帯広市 | ||
| State/Province/Region | 北海道 | ||
| Zip/Postal Code | 0800019 | ||
| Phone Number | 0155-24-4688 | ||
| Country | Japan |
| Full Name | 工藤 英樹 | ||
| Gender | male | ||
| Birthday | 1975-09-26 | ||
| Social Security Number |
| Credit card brand | Diners Club | ||
| Credit card number | 3009050864696539 | ||
| Expire | 2027/4 | ||
| CVV | 757 |