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Registration form |
SARS e-Conference by
WHRMC organized
jointly by
Union of Risk Management for Preventive Medicine
Asia
Pacific Society of Risk Management for Preventive Medicine
(Please
type. Fax till October 5, 2003) to be held on internet
in October 10-14, 2003.
Male □ Female
□
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▲Surname
▲ Town
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▲First name
▲Country
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▲Title
▲ Telephone (country code, are
code, number)
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▲Organization
▲Fax
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▲Mailing address
▲E-mail
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▲Postal code
▲Please indicate the name of accompanying persons
A. REGISTRATION
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Please
note that the registration is not valid until the payment has been received.
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US$/PERSON |
No. of
persons |
US$/total |
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URMPM member |
50.00 |
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Non-member of URMPM |
100.00 |
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Total 1) |
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B.
PAYMENT |
Please pay at the time of
registration by either following method.
(Type A) International credit card
VISA and MASTERCARD are available.
Please fax this form to 81+3+3400-0131,
after you embed the followings.
A total amount of your payment:
Japanese Yen (equivalent to
US$)
your credit card company: VISA / MASTERCARD (please mark either.)
card number:
your name on the
credit card:
valid date of
the credit card:
(Type B) Bank transfer
Please remember to indicate
the name of the delegate on the money transfer.
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Note that we cannot accept personal cheques,
Eurocheques, or company cheques! |
■Bank Transfer to:
Bank: MIZUHO Bank
Branch: OIZUMI
Address: Oizumi,
Nerima-ku, Tokyo, Japan
Account holder: JSRMPM
Account number: 8021403
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C.
ABSTRACT |
Abstract submission: YES □ NO □
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Please fill all in this
Registration Form, and fax them to the Center shown in the
below. All charged participants who
will use bank transfer, should also fax copies of APPLICATION FOR
REMITTANCE and STATEMENT OF REMITTANCE of your bank transfer. After this registration, the Abstract
Submission Form should be e-mailed to the corresponding Registration
Office by September 10, 2003.
The e-mail address appears in the Abstract Submission Form.
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Please
return this FORM, APPLICATION FOR REMITTANCE and STATEMENT OF REMITTANCE by
fax to Registration Office: World
Health Risk Management Center, Fax:81 (3)3400-0131 |
(Postal address)
World Health Risk Management Center
c/o JSRMPM Office
Aoyama