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. |