| Street | 1 Chome-307-6 Inaho | ||
| City/Town | 長岡市 | ||
| State/Province/Region | 新潟県 | ||
| Zip/Postal Code | 940-0884 | ||
| Phone Number | 0258-24-2733 | ||
| Country | Japan |
| Full Name | 青田 加奈 | ||
| Gender | female | ||
| Birthday | 1978-07-30 | ||
| Social Security Number |
| Credit card brand | Discover | ||
| Credit card number | 6011246696143810 | ||
| Expire | 2030/9 | ||
| CVV | 612 |