Please fill out the following form.
Print clearly, block letters preferred.
Family Name: |
________________________________________________ |
Given Name: |
________________________________________________ |
Pen Name: |
____________________________________________________________________ |
Sex: |
(Circle one) Male / Female |
Date of Birth: (optional) YYYY/MM/DD |
_______________________________________ |
Occupation: |
________________________________________________ |
Address: |
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________ |
ZIP Code: |
________________________ |
Country: |
_________________________ |
Telephone No.: |
________________________________________________ |
Tele-FAX No.: |
________________________________________________ |
E-mail Address: |
______________________________________________________________ |
I give you permission to use my application data for future cons.:(Circle one) |
Yes / No |
Application Category:(Circle one) |
Full-attending / Supporting |
Remittance date: YYYY/MM/DD |
_______________________________________ |
for the handicapped
Pacifico Yokohama convention center is a barrier-free facilities. If there is anything about your disabilities we can assist you with, please do not hesitate to inform us. One attendant can accompany a participant free of charge.
Name of your attendant, if one will accompany you. |
Family Name: |
________________________________________________ |
Given Name: |
________________________________________________
The name of the attendant can be changed at anytime. |