Registration form

Dead line: October 13, 2012

SSS'12 Advanced Registration Form
E-mail or Fax to: Tomonori IZUMI, SSS'12 Secretary, E-mail: sss12@sci-sss.org, Fax: +81-3-5481-5844

Corresponding Address
Note:

The proceeding CD-ROM(s) will be sent to the corresponding address.
If you have a specific request on the delivering of CD-ROM(s), please give details.

Title(If you are a resident in Japan, please give your Address (and Name) also in Japanese)

Name
AddressPhone
FAX
E-mailRegistrations
Registrants

Title

Name

Affiliation

Type of registration

123
45

Subtotal of registrations:

JPY

Options
Note: One proceedings CD-ROM and one banquet ticket are included in Full Registration.

Optional Proceedings CD-ROM

5,000JPY eachX

Quantity:=

JPY

Optional Banquet Ticket

6,000JPY eachX

Quantity:=

JPY

Subtotal of options:

JPY

TOTAL:

JPY

Lunch (no charge)
Do you need Bento lunch boxes?

NO

Nov/01

YESNO

Nov/02

YES

To participants of banquet and guests of hotels:NO

Do you have any food restrictions?

YES(if YES, please detail your restriction)

Payment
Check your payment method

Bank Transfer

PaypalVISA

Please fill in the following blanks (bank information):
Amount of remittanceJPY

Name of remitter (or paypal account id)
Completed of expected date of remittance

Please fill in the following blanks (VISA card information):
Cardholder's Name
Credit Card No.
Expiration Date (month/year)/(MEMO)

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SampleDead line: October 13, 2012

SSS'12 Advanced Registration Form
E-mail or Fax to: Tomonori IZUMI, SSS'12 Secretary, E-mail: sss12@sci-sss.org, Fax: +81-3-5481-5844

Corresponding Address
Note:

The proceeding CD-ROM(s) will be sent to the corresponding address.
If you have a specific request on the delivering of CD-ROM(s), please give details.

Title

Prof.

(If you are a resident in Japan, please give your Address (and Name) also in Japanese)

Name

Taro Kokushikan

国士舘 太郎Address

Department of Computer and Systems Engineering, Kokushikan University
4-28-1 Setagaya, Setagaya City, TOKYO 154-0017 JAPAN

154-0017 東京都世田谷市世田谷4-28-1 国士舘大学 情報システム工学科

Phone+81-88-592-XXXX

FAX+81-88-592-YYYY

E-mailaaa@bbb.com

RegistrationsRegistrants

Title

Name

Affiliation

Type of registration1Prof

Taro Kokushikan

Kokushikan University

Full Reg.(member): 21,000JPY

2Mr.

Ichiro Kokushikan

Kokushikan University

Student Reg.: 5,000JPY

345

Subtotal of registrations:

26,000

JPYOptions
Note: One proceedings CD-ROM and one banquet ticket are included in Full Registration.

Optional Proceedings CD-ROM

5,000JPY eachX

Quantity:

1=5,000

JPY

Optional Banquet Ticket

6,000JPY eachX

Quantity:

1=6,000

JPY

Subtotal of options:

11,000JPY

TOTAL:

37,000JPY

Lunch (no charge)
Do you need Bento lunch boxes?

X

Nov/01

NO
YES

NO

Nov/02YESXTo participants of banquet and guests of hotels:
Do you have any food restrictions?

XNOYES(if YES, please detail your restriction)

Payment
Check your payment method

Bank Transfer

PaypalX

VISA

Please fill in the following blanks (bank information):
Amount of remittance

38000

Name of remitter (or paypal account id)

Taro KoKushikan (aaa@bbb.com)

JPY

Completed of expected date of remittanceOct/10/2012

Please fill in the following blanks (VISA card information):
Cardholder's Name
Credit Card No.
Expiration Date (month/year)/(MEMO)This is a sample sheet.

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