書き方のSAMPLE（日本心臓病学会 会員用）
ACC International Associate/
Affiliate Application
I am applying as a:
❑ Cardiovascular Specialist (International Associate Member)
✓
❑ Non-Cardiovascular Physician/Scientist (Affiliate Member)
Complete the form and return by email, post, or fax to:
American College of Cardiology
Member Services Department
2400 N Street, NW
Washington, DC 20037, USA
Email: mdavis@acc.org
Fax: +1 202-375-6843 • Phone: +1 202-375-6000, ext. 5439
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❑ Male ❑ Female
10/22/1973
_____________________________
Birth Date (Month/Day/Year)
Hongo University
____________________________________________________________________________________________________________________________________________________
Name of Institution
Tokyo, JAPAN
Internal Medicine
Location (City/Country)
Area of Specialization
March,2000
____________________________________________________________________________________________________________________________________________________
Graduation Date
Training Program
Bunkyo Hospital
Name of Institution
Tokyo, JAPAN
Internal Medicine
Location (City/Country)
Area of Specialization
March,2001
____________________________________________________________________________________________________________________________________________________
Ichiro
SUZUKI
____________________________________________________________________________________________________________________________________________________
(Middle Initial) Medical School
______________________________________________________________________________________________________________________________________________________
Personal Data (All Sections Must Be Completed)
Full Name (First)
Education, Training and Society Membership
(Last)
international@jcc.gr.jp
✓
______________________________________________________________________________________________________
Please provide business or personal email addresses and check a box to indicate preferred email for ACC communications. ❑ Business ❑ Personal
Dept. of Internal Medicine, Bunkyo Hospital, 4-9-22 Hongo, Bunkyo-ku
____________________________________________________________________________________________________________________________________________________
Graduation Date
Japanese College of Cardiology
日本心臓病学会の会員は、この通り記入
❑ I am a member of a recognized medical society* ______________________________________________________________________________________________________
✓
して下さい。
Name of Society
*Those without medical society memberships will need to submit a sponsor letter from a current ACC member
Medical Practice or Appointments
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❑ Licensed or certified to practice medicine __________________________________________________________________________________________________________
Hongo University, Tokyo JAPAN
Name of Authorizing Body
Preferred Address
Tokyo
JAPAN
113-0033
____________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________
❑ Academic or research appointment
Name of Authorizing Body
City, Province/StateCountryPostal Code
+81-3-5802-0112
+81-3-5802-0118
____________________________________________________________________________________________________________________________________________________
Office TelephoneHome TelephoneFax
Please indicate your top three areas of interest relevant to your primary clinical activities by entering 1, 2, and 3 below:
Principal Employment Information (For Public & Membership Directory)
Dept. of Internal Medicine, Bunkyo Hospital
____________________________________________________________________________________________________________________________________________________
Institution/Practice Name
Associate Professor
____________________________________________________________________________________________________________________________________________________
Title/Position
4-9-22 Hongo, Bunkyo-ku
____________________________________________________________________________________________________________________________________________________
Address
Tokyo
JAPAN
113-0033
____________________________________________________________________________________________________________________________________________________
City, Province/StateCountryPostal Code
+81-3-5802-0112
+81-3-5802-0118
____________________________________________________________________________________________________________________________________________________
TelephoneAlternate TelephoneFax
Which of the following best describes your work setting?
❑ Solo Practice ※個人開業
❑ Government Hospital or Agency ※公立病院、公立機関
❑ Industry ※民間病院、民間企業
❑ Other (please specify) __________________________________________________________
✓
Areas of Interest
❑
❑
❑
❑
1
❑
❑
❑
❑
❑
❑
❑
❑
Administration
Adult Cardiology
Adult Congenital Cardiology
Anesthesiology
Arrhythmias & Devices
Cardiac Rehab
Cardiothoracic Surgery
Congenital Card. Surgery
Critical Care Medicine
Echocardiography
Electrophysiology
Emergency Medicine
❑
❑
❑
❑
❑
2
❑
3
❑
❑
❑
❑
❑
❑
Endocrinology
Family Practice
General Cardiology
Geriatrics/Aging
Health Policy
Heart Failure/Transplant
Hypertension
Internal Medicine
Interventional CV
Invasive CV
Lipids Clinic
MR/CT
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
Nuclear CV
Nuclear Medicine
Pathology
Pediatric CV
Pediatric Interventional CV
Pediatrics/Neonatal
Pharmacology
Physical Medicine
Physiology
Preventive CV
✓
Pulmonary Disease⎯
Radiology
Research
Sports & Exercise CV
Thoracic Surgery
Transcatheter Valve Therapy
Vascular & Interventional Radiology
Vascular Medicine
Vascular Surgery
Other
______________________________________
Public Health
Membership Dues Payment
Please enclose payment to ensure your application is processed. All applications are subject to a $25 one-time application fee.
What is the ownership structure of your practice?
❑ Government Owned
❑ Hospital Owned
❑ Insurance Company Owned
❑ Medical School/University Owned
❑ Other (please specify) __________________________________________________________
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
Nephrology
þ Application Fee $25 ❑ Hardcopy JACC $170
Annual Dues:
❑ CV Specialist, High-Income Country $125
✓
❑❑ CV Specialist, Middle/Low-Income Country $100
Payment Method:
❑ Check or money order enclosed. In US dollars drawn on a US bank.
VISA, MasterCard. Discover
クレジットカードの背面に記載されたメイ
ンのカード番号の後に書かれた3桁の番号
❑❑ Non-Cardiovascular Physician/Scientist, High/Mid/Low $100
❑
✓
❑ ❑ MasterCard ❑ Visa ❑ American Express ❑ Discover
ICHIRO SUZUKI
___________________________________________________________________________________________________________________________________________________
Cardholder Name
1234 5678 9123 4567
03/2017
891
___________________________________________________________________________________________________________________________________________________
Card Number
Expiration Date
CSC #