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Registration form |
The 1st International
Forum of Patient Safety
by World Health
Risk Management Center (WHRMC)
to be held in Tokyo,
January 23-24, 2006.
(Please type) All speakers should fax this form till January 10, 2005
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Male @@@@ @Female
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£Surname
£ Town
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£First name
£Country
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£Title
£ Telephone (country code, are
code, number)
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£Organization @£Fax
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£Mailing address £E-mail
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£Postal code
£Please indicate the name of accompanying persons
A.
REGISTRATION FEE
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Please
note that the registration is not valid until the payment has been received.
URMPM MEMBER
for presentation
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US$/PERSON |
No. of participants |
US$/total |
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400 $ |
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Non URMPM MEMBER
for presentation
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US$/person |
No. of participants |
US$/total |
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500 $ |
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Total |
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(Note The fees
include the reception and banquet on January 23, 2006.
Those donft cover your hotel
accommodation.
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B. ACCOMODATION
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The Conference place locates in
Tokyo.
For discount hotels, consult http://www.e-hoteljapan.com/.
The above tourists are also
available for hotel accommodation on their English homepages.
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C.
PAYMENT WAYS |
Following
payment manners of participation fee are available.
(1)
PAYMENT ON CONFERENCE DESK (only for audiences)
by cash (US$ or Japanese Yen),
only..
(2) CREDIT CARD (for all speakers and
audiences)
If you want to pre-pay, send
your fee by credit card till December 31, 2005.
VISA or MASTERCARD are acceptable. Send
the following information with this registration form by fax.
1)
Card number:
2)
Your name on the card:
3)
Valid date:
4)
A total of payment amount:
Donft send your signature and
the secret number of the card!
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Please fill all in this
Registration Form, and fax them to Registration Office shown
in the below. Your Abstract Form
should be e-mailed to the corresponding Registration Office by October
15, 2005. The e-mail address
appears in the Abstract Submission Form.
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Please
return this FORM, APPLICATION FOR REMITTANCE and STATEMENT OF REMITTANCE by
fax to WHRMC Registration Office: Ms. Kazue Moriyama c/o Kato & Ooka
Lab., Institute of Industrial Science, The University of Tokyo.
(Fax) +81-3-5452-6432 81 is a country code of Japan) |