FDMアジアンアソシエイション

Application Form

*1. Name
(First name, Family name)

氏名
required
*2. Gender
(Mr. or Ms.)

性別(Mr.男性またはMs.女性)
required
*3. Declaration of membership
(FAA, EFDMA, AFDMA, AFDMS or other)

所属団体(学生は学校名)
required
*4. Home address
(postal code, city, street, country)

住所
required
*5. Phone number
(including country code)

電話番号
required
*6. Professional qualifications
(FDM-IC, MD, DO, PT, etc)

国家資格あるいは学生、一般
required
*7. Clinic or Office Name
治療院名(学生は”学生”を記入してください。)
required
*8. Email Address
メールアドレス
required
*9. Confirm Email Address
メールアドレス確認required
*10. Will you join the 1st day?
(Yes or No)

1日目学会(参加または不参加)
required
*11. Will you join the 2nd day?
(Yes or No)

2日目学会(参加または不参加)required
*12. Will you join the 3rd day?
(Yes or No)

3日目セミナー(参加または不参加)required
*13. Will you make a presentation?
(Yes, No, Not decided)

学会発表希望(あり、なし、未定)required
*14. Will you join the Round Trip?
(Yes or No)

旅行 参加または不参加required
*15. Number of those joining Round Trip
旅行参加人数required
*16. Names and gender of Round Trip participants
旅行全参加者氏名性別
(Fill in "0" if you do not join.)
(不参加は“0”を記入してください)required
*17. 食事 (Meals - Regular or vegetarian)
required
*18. Arrival date and flight number
(Fill in "0" if you do not join from overseas.)

(国内参加者は“0”を記入してください。)
required
*19. Departure date and flight number
(Fill in "0" if you do not join from overseas.)

(国内参加者は“0”を記入してください。)
required
*20. The name of your hotel
(Fill in "0" if you do not join from overseas.)

(国内参加者は“0”を記入してください。)
required
Inquiry concerning the Congress
学会お問い合わせ
Inquiry concerning the Round Trip
旅行お問い合わせ