To: The Secretariat of the JGA [ E-mail : , FAX : +81-3-3814-6904 ]
JGA's Accounting Period is from January 1 to December 31 of each year.
Contact:
The Japanese Gastroenterological Association
2-1-1Suido, Bunkyo-ku,
Admission Application Form
Date:
d d / m m / y y y y
Tokyo, 112-0005, Japan
TEL: +81-3-5840-6338
The required items indicated with * below must be completed.
i.e.) SHOKAKAN
Surname*
i.e.) Taro
Middle
First name*
Name
Gender*
□Male □Female
Birthday*
d d / m m / y y y y
Office
(Name of the
Affiliation)*
Job
Department*
Title
□ non particular
Office
Address*
Postal Code:
Country:
(Ext: )
TEL*
FAX
Office Contact
Info*
E-mail
@
Home Address*
Postal Code:
Country:
TEL*
FAX
Home Contact
Info*
E-mail
@
Majored in
Faculty
Name of the College / University
Year of Graduation
Academic
Background*
Name of the Graduate School
Year of Graduation
i.e.) M.D. PhD
Occupational
Highest
□Physician □ Veterinerian □ Pharmacist □ Others
Category*
Degree
Specialized
Field*
(up to 8
categories)
Other
Belonging
Societies
(up to 6)
Do you wish your name and
Which do you
affiliation be listed on the
prefer to be
□ Office □ Home
□ Yes □ No
member's roll which might be
contacted at?*
relieased in public?*
Please understand that if you check No, there might be a possibility
that you might not receive a certain announcements from the secretariat.
If applicable, please fill in below:
The person who recommended JGA to you
Affiliation / Society of the person who recommended JGA to you
Recommended
by
A1-201006