< Deadline : May 7, 2015 >☆YOU MUST TYPE OR PRINT CLEARLY!!☆
1Name(Exactly as itappears inpassport)

2

Date of Birth

Last Name

MonthFirst Name

DayMiddle Name

Year

3. Age4. Gender

Street:5Address

City:
State:

6

Telephone

7Fax

8E-mail address

9 Occupation / Grade

Zip:
Cell:

@Discount :□ Child Discount* 11 years and under: $200 discount.

□ Student Discount□ Infant under 2 years old* Student between 12 & 25 years.: $100 discount.

*Infant: $300 fo all costs

10 Hobbies / Interests
11Allergies

12Pets13

Are you a smoker?

14Like・Dislike

What kind of pets do you dislike?

Do you mind if your host family smokes?
Foods you can't eat / won't eat.

15
Special Needs /Note to Host Family
16

Family Members (This information helps us match you with a similar family in Japan)
Name

Relationship

Occupation

Age

17

Preferred Hotel Companion?
18 (All rooms are based on double occupancy. Single participants will be paired Name:up with another participant to share a room)

19 Would you prefer a single room in the hotels? (at extra cost)
Basically, one participant stays at one host's house. However, because of
20 special reason (wife and husband, parent and child, etc.), if you want tohomestay with someone else, please write his/her name. (Due to the house
space, this request may not be guaranteed.)

YES
NAME

・NO
RelationshipDeparture/ Arrival Airport
Please insert the number and name of Airport will you use.
21

1. Seattle 2. San Francisco 3. Los Angeles 4. San Diego 5. Denver 6. Colorado Springs
7. Dallas 8. Houston 9. Austin 10. Atlanta 11. New York 12. Washigton 13. OtherYou Choice: (______)__________________________________OPTIONAL LOCAL TOURS on July 8th
Please insert the alphabet and name of your 1st and 2nd choices.
(Please see the brochure for Local Tours details.)
22

A: Beppu Nature

B. Unique Oita

C. Kitsuki Beautiful History D. Yufuin Relax Course E. Beppu Learning

1st choice: (______)__________________________________

2nd choice (_____)____________________________________

LOCAL SESSION CHOICE
Please insert the number and name of your 1st and 2nd choices.
(Please see the brochure for Local Session details. Your preference will be considered, but not guaranteed.)

1. Oita 2.Usuki 3.Tsukumi 4.Saiki 5.Taketa 6.Hita
7. Nakatsu 8.Usa 9.Bungo-Takada 10.Kitsuki 11.Beppu

23

1st choice: (______)__________________________________

2nd choice (_____)____________________________________POST SUMMIT OPTIONAL PROGRAM from July 13th
Please insert the alphabet and name of your 1st and 2nd choices. (Please see the brochure for the details.)
24

OP1. Kumamoto & Tokyo OP2. Kyoto & Tokyo
OP4. Tokyo Free Time (1st : (_____)________________________________________

If you prefer a single room at the hotel during the optional program,
25 please check the right box. (at extra cost of $80 / night)

OP3. Fukushima & Tokyonights)

2nd : (_____)_____________________________________________
If you want to extend your stay in
26
Tokyo, how many nights? ($125/night)nightsTRAVEL INFORMATION
27 Passport Number:

28 Nationality:

29 Passport Expiration Date (DD/MM/YYYY) :30 Person(s) traveling with you://

31 Desired Departure Date / Desired Return Date:
32 Special Request (meals, desired seating etc.)
33 Do you require travel insurance?

Yes / No (Travel insurance is your own responsibility)

KIMONO(YUKATA) SIZE
The following information is needed by the hotels to help them choose
appropriate yukata (cotton kimono) for you. Please choose from list right (e.g.
medium). If your size is not in the list, please write it in inches.
34 YUKATA Size: ( Adult / Child )_________________________________________________________

Please send this application form
with your passport copy to:
U.S. Desk at Nippon Travel Agency America, Inc(Greater Los Angeles Branch)
Attn: Grassroots Summit in 2015

■YUKATA Size (for Adult)
Size
HeightSmall
4.5 - 5.2 feetMedium
5.2 - 5.7 feetLarge
5.7 ～ feet

■YUKATA Size (for child)
Size
HeightSmall
2.2-3.0 feetMedium
3.0-3.8 feetLarge
3.8-4.3 feet
[ CONTACT ]REGARDING TRAVEL

Address: 1025 West 190th St., Gardena CA 90248
Tel: 310-808-2716, Fax: 310-630-0896
Email: grassroots_summit@ntaamerica.com
Contact: Linda Cockrell or Minoru Ueda

(special flight arrangements or considerations)
Please contact Linda Cockrell orMinoru Ueda of NTA America【 Office hour : 9:00 am - 5:30 pm PST, Mon.- Fri. 】

Passport Copy: Please make a photocopy of the page ofyour name, passport number, expiration day.

REGARDING THE SUMMIT:
CIE-US (C/O NAJAS)
Telephone: 202-429-5545 ( Washington DC)
E-mail : manjiro@us-japan.org

THE DEADLINE IS MAY 7, 2015
*The program organizers reserve the right to approve, deny or cancel any application at their discretion and to alter the program and activities at any time.