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The 13th Scientific Meeting
The Asian Academy of Craniomandibular Disorders |
REGISTRATION FORM
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| Office Use Only |
Registration No.: |
Date Received.: |
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| PARTICIPANT |
| Name : (First) (Last) |
| Degree/Specialty : Position: |
| Clinic/Department : |
| Institute : |
| Address : |
| City/State : Zip Code : Country : |
| Phone : Fax : E-mail : |
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| ACCOMPANYING PERSON(S) |
Name :  Mr. Ms. (First) (Last) |
| Name : Mr. Ms. (First) (Last) |
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| RESISTRATION FEES |
Classification
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Before
Aug.31.2010 |
After
Sep. 1.2010 |
Number of person |
Amoount |
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Member |
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JP 10,000 |
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JP15,000 |
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 |
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Non-Member |
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JP15,000 |
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JP20,000 |
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Accompanying |
|
Person |
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JP5.000 |
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JP10.000 |
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Total
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JP |
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| PAYMENT METHOD |
Send directly to the bank account only.
*Account: The Bank of FUKUOKA Ltd． Minamikokura branch, Kitakyushu, Japan, Swift Code：FKBKJPJT
1620113, AACMD JSOP SHUNJI SHIIBA
*Please indicate Resistrant's name in the "Application for Remittance" form and send a copy of the bank receipt confirming your remittance along with the registration form to the Organizing Committee |
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Please complete this form
and send it with your payment by mail or by fax or E-mail to the Organizing Committee
Division of Dental Anesthesiology, Kyushu Dental College,
2-6-1, Manazuru, Kokurakita, Kitakyushu,Fukuoka,803-8580,JAPAN
Tel: +81-93-582-1131 Fax:+81-93-582-1139
E-mail: shiiba@kyu-dent.ac.jp Homepage: http://acmd-jsop.kyu-dent.ac.jp |
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