FORM A

International Symposium on Isotopomers

Yokohama 23-26 July 2001

Registration Form

_______________________________

Please complete this form and e-mail or fax it to the address below by 10 April, 2001 (early registration), or by 20 June, 2001 (late registration)

 

Japan Travel Bureau Inc. Yokohama Office

15F, Yokohama Nishiguchi KN Bldg.
2-8-4 Kitasaiwai, Nishi-ku, Yokohama 220-0004
, JAPAN

E-mail: danyoko9@mnm.jtb.co.jp

Fax: +81-45-316-5703

 

1. Registration (Please type or print in block letters)

Title: (please check boxes)

[    ] Mr.    [    ] Ms.    [    ] Dr.    [    ] Professor

[    ] Student (please attach a certificate)

Family Name:                                                                         

Given Name:                                                                          

Middle Name Initial: ______

 

Affiliation:

                                                                                                                                                                                                                                                                  

 

Mailing Address:

                                                                                                                                                                                                                                                                                                                                                                                                   

Postal Code/Zip Code:                         Country: ______________________

 

Phone:                                                            Fax:                                                   

(Please include country and area codes.)

 

E-mail:                                                                                                                     

 

If you are accompanied by anybody, please fill in below:

 

Name                                                                                                                       

 

2. Food and Beverage Fee (please check boxes)

(1) Icebreaking party (23 July, evening)

Registered

on / before 10 April, 2001

Registered after 10 April, 2001

Active Participant

[  ] 1,500 JPY

[  ] 2,000JPY

Accompanied person or Students

[  ] 1,500 JPY

[  ] 2,000JPY

108 JPY (Japanese Yen) per $1 U.S. (as of November, 2000)

See http://www.travlang.com/money/ for currency exchange information.

 

(2) Banquet and special session (25 July, evening) at the Sankeien Garden, a traditional garden of Japanese historical mansion facing to the Pacific

Registered

on / before 10 April, 2001

Registered

after 10 April, 2001

Active Participant

[  ] 7,000 JPY

[  ] 8,000 JPY

Accompanied person or Students

[  ] 5,000 JPY

[  ] 6,000 JPY

 

(3) Coffee-breaks (24-26 July)*

Registered

on / before 10 April, 2001

Registered

after 10 April, 2001

Active Participant

[  ] 1,500 JPY

[  ] 2,000 JPY

Accompanied person or Students

[  ] 1,500 JPY

[  ] 2,000 JPY

*We would like all participants in the symposium to check the box.

 

Total Fee [(1)+(2)+(3)]:             JPY

 

3. Payments (Please type or print in block letters)

Please check your payment method (by credit card (we recommend) or by bank transfer).

 

[    ] By credit card

 [    ] VISA     [    ] MasterCard   [    ] Diners Club

 

Card Number   : _________________________________________

Expiry Date    : __________/__________ (month/year)

Card Holder's Name:                                                                               

Signature         : ___________________________________

Date: ________/_________/_________ (day/month/year)

 

 [    ] By bank transfer          Sender's name [                                            ]

 

      Account name :  Japan Travel Bureau, Inc.

      Account number.: 0043079 (ordinary account)

      Bank name : The Bank of Tokyo Mitsubishi

      Branch name: Yokohama Branch

 

Please make sure to remit the amount with all banking charges on your account and attach the copy of bank transfer evidence to this registration form.

 

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