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
   　　  

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                                                           	
Please note that the registration is not valid until the payment has been received.

URMPM MEMBER for presentation	US$/PERSON	No. of participants	US$/total     	
	400 $ 			
Non URMPM MEMBER for presentation	US$/person	No. of participants	US$/total    	
	500 $			
Total 	
(Note The fees include the reception and banquet on January 23, 2006.
   Those don’t cover your hotel accommodation.
.   　

B.  ACCOMODATION	
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. 

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:  

Don’t 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.

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)