DIA Japan MEMBERSHIP APPLICATION 会員申込書
Register online at DIAglobal.org/Membership or email this form to Japan@DIAglobal.org

重要：お手数ですが、世界共通の会員登録の都合上英語でご記入ください

MEMBER CONTACT INFORMATION 登録会員情報 (必須)

PAYMENT OPTIONS 支払方法 (必須)
Register online at DIAglobal.org/Membership or by:
 ONE (1) YEAR MEMBERSHIP 年会費 29,150 YEN *CONSUMPTION TAX INCLUDED/消費税込

 NEW MEMBER 新規  RENEWAL 更新

LOCK-IN FOR TWO YEARS AND SAVE 10%
 TWO (2) YEAR MEMBERSHIP 52,470 YEN *CONSUMPTION TAX INCLUDED/消費税込
ACADEMIA MEMBERSHIP (ACADEMIA, MEDICALS) ONE(1) YEAR MEMBERSHIP 21,450 YEN *CONSUMPTION TAX INCLUDED/消費税込
 TWO (2) YEAR MEMBERSHIP 38,610 YEN *CONSUMPTION TAX INCLUDED/消費税込
STUDENT MEMBERSHIP ONE(1) YEAR MEMBERSHIP 6,600 YEN *CONSUMPTION TAX INCLUDED/消費税込

Last Name 姓First Name 名M.I.

 Dr.

Degrees 学位 (PhD, MD等)

 Mr.

 Ms.

STUDENTS WHO BELONG TO A COMPANY OR WHO ARE RECEIVING REMUNERATION FROM A COMPANY ARE NOTELIGIBLE/STUDENT MEMBERはどの企業にも所属しておらず且つ報酬を得ていない方が対象です。
PLEASE SEND THIS FORM WITH A COPY OF YOUR STUDENT ID TO DIA JAPAN OFFICE BY FAX OR E-MAIL/この用紙に学生証を添付し、お申込ください。

Job Title 役職名

 CREDIT CARD クレジットカード Complete this form and email to Japan@DIAglobal.

org
この用紙をダウンロードし必要事項にご記入の上、Eメールにて Japan@DIAglobal.org宛てにお送りください。

Company 会社名

Mailing Address (as required for postal delivery to your location) 刊行物郵送先住所

Address is この住所は:  Office 会社  Other その他

Department 部署名

 Visa  MasterCardExp Date 有効期限(mm/yy) ̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲Card # カード番号 ̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲Name (printed) ______________________________________________________

Street Address ビル名、番地、町名

Signature 署名 ______________________________________________________

 BANK TRANSFER 銀行振込 MIZUHO BANK LTD., Kamiyacho branch,
City 区・市State 都道府県

Zip/Postal Code 郵便番号

Country 国名

Tranomon 45 MT Bldg., 5-1-5 Toranomon, Minato-ku, Tokyo 105-0001,
Japan DIA Japan Ordinary Account Number: 1273382, SWIFT CODE # MHCBJPJT.
みずほ銀行 神谷町支店 普通1273382（口座名義）一般社団法人ディー・アイ・エー・ジャパン

 REQUEST INVOICE 請求書希望 Email your information to Japan@DIAglobal.org
Telephone 電話番号Email (required for confirmation)

Membership will not begin until payment is received.
Eメールにてこの用紙をお送りください（ Japan@DIAglobal.org）。
会員資格は会員費受領を確認してから開始されます。

PLEASE CHECK APPLICABLE CATEGORY Academia/Non Profit  Government  Industry

PROFESSIONAL INTEREST AREAS (任意)
Please select one Primary Interest Area (P) and one Secondary Interest Area (S) by placing a P or S on the appropriate line.

RESPONSIBILITY/INTEREST AREA__ Advertising & Promotion__ CMC__ Clinical Data Management/eClinical__ Clinical Research__ Clinical Safety and Pharmacovigilance__ Document Management/eSubmissions__ Manufacturing__ Medical Communications__ Medical Writing__ Nonclinical__ Outsourcing__ Comparative Effectiveness/HealthTechnology Assessment/Evidence-based Medicine__ Pharmacology__ Pricing/Reimbursement__ Project Management__ Professional Education, Training & Development__ Public Policy/Law/Corp. Compliance__ Quality Assurance/Quality Control__ Regulatory Affairs__ Research & Development__ Statistics__ Strategic Planning__ IT/Validation

Membership is not refundable or transferable. 会員資格はキャンセル、名義変更不可となっております。

Continued on page 2DIA Japan MEMBER PROFILEYour profile allows DIA to provide content specific to your professional development needs.

(任意)How long have you worked in this industry? Select one.
 Less than 2 years 2-5 years 6-10 years 11-15 years 16-20 years

 More than 20 years

How long have you been in your current position? Select one.
 Less than 2 years 2-5 years 6-10 years 11-15 years 16-20 years

 More than 20 years

What is your current work setting? Select one.
 CRO/CSO
 Government Hospital/Medical Practice Independent Consultant
 Industry

 Law Firm
 Press/Media Staffing/Recruitment
 Support services: Staffing/Personnel
 Trade/Professional Organization

 University
 Student Other

What is your current job function? Select one.


Associate
CEO/President
Coordinator
DirectorManagerProfessor/Academic Position
Scientist
Specialist
Vice President

What is your current product responsibility? Select one.
 Biotechnology
 Combination Products
 Dietary Supplements/Natural Health Products Generics
 Medical Devices
 Diagnostics

 OTC Drugs
 Pharmaceutical Products
 Veterinary Medicines

What is the size of the organization you work for? Select one.
 1-50 employees  51-500 employees  501-5,000 employees 15,001- 50,000 employees  More than 50,000 employees

OnlineEmailDIAglobal.org/MembershipJapan@DIAglobal.org

 5,001-15,000 employees

Mail

DIA Japan
Nihonbashi Life Science Building 6F,
2-3-11 Nihonbashihoncho, Chuo-ku, Tokyo 103-0023 Japan