< Deadline : May 1, 2013 >☆YOU MUST TYPE OR PRINT CLEARLY!!☆
Last Name

Name
1(Exactly as itappears in passport)
Month2First NameDay

Middle Name

Year

3. Age4. Gender

Date of BirthStreet: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.: $150 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)

YES

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

NAME

space, this request may not be guaranteed.)

・NORelationship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 guranteed.)

1. Matsue 2. Yasugi 3. Izumo 4. Izumo/Hirata 5. Unnan
6. Okuizumo 7. Ohda 8. Gotsu 9. Hamada 10. Masuda 11. Oki

21

1st choice: (______)__________________________________

2nd choice (_____)____________________________________OPTIONAL LOCAL TOURS on July 3rd
22

A: Deep in the heart of Matsue

B. Adachi Museum of Art and Yasugi-bushi

C. Yuushien Garden and "Gegege-no-Kitaro"

POST SUMMIT OPTIONAL PROGRAM from July 8th
Please insert the alphabet and name of your 1st and 2nd choices. (Please see the brochure for the details.)
23

OP1. Kyoto & Tokyo
OP2. Hiroshima, Kochi & Tokyo
OP4. Sendai & Tokyo
OP5. Tokyo Free Time (1st : (_____)________________________________________
If you prefer a single room at the hotel during the optional program,24 please check the right box. (at extra cost of $45 / night)

OP3. Noto & Tokyonights)

2nd : (_____)_____________________________________________
If you want to extend your stay in
25Tokyo, how many nights? ($145/night)nightsTRAVEL INFORMATION26 Passport Number:

27 Nationality:

28 Passport Expiration Date (DD/MM/YYYY) ://29 Person(s) traveling with you:
30 Desired Departure Airport (City & State):
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 on the list, pleasewrite it in inches.
34

YUKATA Size: ( Adult / Child )_________________________________________________________

Please send this application form
with your passport copy to:
KIE/ Kintetsu International
Attn: Grassroots Summit 2013
Address : 1290 Avenue of the Americas, Suite 900 New York NY 10104

Telephone : 212-259-9710

E-mail : Manjiro@kintetsu.com

Passport Copy: Please make a photocopy of the page ofyour name, passport number, expiration day.
THE DEADLINE IS MAY 1, 2013

■YUKATA Size (for Adult)
Size
HeightSmall
4.7 - 5.0 feetMedium

5.0 - 5.4 feetLarge

5.4 - 5.7 feet

X Large

5.7 feet --■YUKATA Size (for child)
Size
HeightSmall
2.5 - 3.7 feetMedium
3.7 - 4.2 feetLarge
4.2 - 4.4 feet
[ CONTACT ]REGARDING TRAVEL(special flight arrangements or considerations)
Please contact Ms. Mitsuru Matsumura
or Mr. Tatsumi Fukushima of KIE【 Office hour : 9:00 am - 5:30 pm EST, Mon.- Fri. 】
REGARDING THE SUMMIT:
CIE-US (C/O NAJAS)
Telephone: 202-429-5545 ( Washington DC)
E-mail : manjiro@us-japan.org*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.