Registration Form
Please fill out the blanks and check appropriate boxes, and e-mail it to the secretariat
(junko_nikkawa@99.catv-yokohama.ne.jp) by September 15, 2011
A. Delegate Details
Title:
Mr./
Ms./
Dr./
Prof.
Sex:
Family Name:
male /
female
First and Middle Name:
Nationality:
Date of Birth:
Affiliation:
Position Title:
Address
Work
Home /P.O.Box:
Zip Code:
Country:
Tel/Mobile:
Fax:
Email:
Invitation Letter for Visa:
Yes
No
B. Accompanying Person (if any)
Title:
Mr./
Ms./
Dr./
Prof.
Sex:
Family Name:
male /
female
First and Middle Name:
Nationality:
Date of Birth
C. Presentation
Author(s):
Title:
Category:
APA oral session /
APA poster session/
D. Registration Fees
Registration Fee
¥15,000 x
person = ¥
(1)
1/2
Symposium poster session
¥5,000 x
person (APA Meeting only) = ¥
(2)
Excursion Fee
¥10,000 x
person = ¥
(3)
(to be paid at the registration desk in cash of Japanese yen)
E. Itinerary
Flight to/from Tokyo
Arrival Date:
Departed from
Departure Date:
Leaving for
Accommodation:
F. Social Events
Welcome Reception
Farewell Party
Symposium Excursion
With/
Without accompanying person
G. Special Needs (if any)
H. Only for Japanese
日本人参加者は下記の項目にも日本語で記入をお願いいたします。
氏名：
同伴者氏名：
勤務先名：
勤務先住所／
自宅住所：
〒
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