Registration
form	
   SARS e-Conference by WHRMC organized jointly by          
　　    Union of Risk Management for Preventive Medicine
   	Asia Pacific Society of Risk Management for Preventive Medicine
(Please type. Fax till October 5, 2003)   　　  　　　　　　　     to be held on internet in October 10-14, 2003.

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                                                            	
Please note that the registration is not valid until the payment has been received.
	US$/PERSON	No. of persons	US$/total     	
URMPM member 	50.00			
Non-member of URMPM	100.00			
Total 1)	
                                            
B. PAYMENT	
Please pay at the time of registration by either following method.

(Type A)  International credit card
 VISA and MASTERCARD are available.  
Please fax this form to 81+3+3400-0131, after you embed the followings.
 A total amount of your payment:             Japanese Yen (equivalent to         US$)
your credit card company:   VISA  /   MASTERCARD  (please mark either.)
card number:  
 your name on the credit card: 
 valid date of the credit card:

(Type B)  Bank transfer 
Please remember to indicate the name of the delegate on the money transfer.

              Note that we cannot accept 
personal cheques, Eurocheques, or company cheques!	
■Bank Transfer to:                                                                                                
  Bank:  MIZUHO Bank                                                                                                 
  Branch: OIZUMI 
  Address: Oizumi, Nerima-ku, Tokyo, Japan
Account holder: JSRMPM 
Account number: 8021403                      

C. ABSTRACT 	
Abstract submission:   		YES　□   		NO　□

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Please fill all in this Registration Form, and fax them to the Center shown in the below.  All charged participants who will use bank transfer, should also fax copies of APPLICATION FOR REMITTANCE and STATEMENT OF REMITTANCE of your bank transfer.  After this registration, the Abstract Submission Form should be e-mailed to the corresponding Registration Office by September 10, 2003.  The e-mail address appears in the Abstract Submission Form.

Please return this FORM, APPLICATION FOR REMITTANCE and STATEMENT OF REMITTANCE by fax to 
 Registration Office:
World Health Risk Management Center, 
Fax:81 (3)3400-0131 

(Postal address) 
World Health Risk Management Center
c/o JSRMPM Office
Aoyama Asia Manson #109
2-5-12 Shibuya, Shibuyaku, Tokyo, 150-0002, Japan.