东京都港区新桥六丁目 8-1 ●
Tel : 03-5422-1516 ●个人会员申请书

Individual Membership Application Form●
●Membership Type Applied For 会员类型：⃞Member 会员（过去或现在担任独立董事 Current/PastINED）*●Personal Particulars

个人信息Title: Mr / Mrs / Miss / Ms / Dr / Prof 英文称呼

Name 姓名

Surname 姓（罗马英文）

Forename 名（罗马英文）

Date of Birth 生年月日

ID Card/Passport No. 本人身份证件/护照号码 Nationality 国籍/地域

Residential Address 住所

Company Address 公司所在地

Tel 电话号码（住宅）Tel 电话号码（公司）Correspondence Address联络地址⃞Residential 住宅 ⃞Company 公司

Mobile 手机号码●Education/ Professional Qualifications

Gender 性別Email 电子邮件学历及专业资格

Name of Institution/University/Professional Body
学院/大学/专业机构名称

Qualification attained
证书/资格の名称

Date Attained
取得日期(Please use on separate sheets if necessary. 如有需要请另页书写)●Work and Independent Non-Executive Director Experiences 职业履历及独立董事相关经验Applicant’s Experience 申请人履历： Total Work Experience 全部工作经验Years 年
INED / Equivalent Experience 独立董事相关工作经验Years 年
List of INED directorships, current and past, in chronological order. 请按时间顺序列举过去及现在独立非执行董事相关工作经验From(mm/yyyy) (月/年)起●Details Of Current EmploymentTo(mm/yyyy) (月/年) 止Company Name 公司名称

现就职公司的资料Company Name 公司名称（中英文）Position held 职务名称（中英文）Company Website 公司网址Company Principal Activities 公司主营业务Co Legal Status (by inserting ✓in the box) 公司类型 (在方格内标注「✓」)⃞Listed co 上市公司 ⃞Private limited co 私人有限公司⃞Statutory or public or non-profit organisations 特殊法人、公营企业或公益法人 ⃞Sole proprietorship 独资经营构 Others その他：●⃞Partnership 合伙企业⃞Subsidiary of overseas co 海外机构之附属机Declaration 声明(i)

I declare that the information given in this application form is true, correct and not misleading.
本人声明，本申请表所填信息真实准确、没有误导。
(ii) I confirm that I have not been disqualified by Court Order or competent authority from being a director.
本人确认不会被法院或主管机关剥夺独立董事的资格。
(iii) I hereby apply for membership of The Japan Independent Director Association (the “Association”) and undertake to abideby the Association’s Articles of Association as amended from time to time.
本人现申请成为日本独立董事协会（以下简称协会）的会员，并同意遵守协会随时更新的《组织章程》。
(iv) I understand and accept the arragement of the Association to regularly communicate with me on events, updates,membership, services, projects, publications and newsletter. I understand that I may exercise the following option byinserting ü in the box: 本人同意并接受协会定期向我发送有关协会的最新活动、咨询、会籍事宜、服务、项目、刊物及会务通讯，也了解本人可以在下列方格内记入「✓」进行选择。
I DO NOT wish to receive above communications from the Association.
⃞本人不希望接收以上协会资讯(v) I have read and understand the following declaration regarding personal data collection:
本人已阅读并了解下列关于个人资料的搜集说明。
Data subjects who may opt out from receiving communications may notify the Association in writing. Data subjects have aright of access and correction regarding their respective personal data and may require the Association to cease to use thedata. Requests can be directed to the Association by post at 6-8-1 Shinbashi Minato-ku Tokyo. Personal data collected bythis document will be used to process application for membership and facilitate communications by post, email andtelephone. For inquiries, telephone 03-5422-1516.
资料当事人如果希望停止收取资讯，可以通过书面方式通知协会。资料当事人有权查阅及更正其相关个人资料，可以要求停止使用该资料。书面通知请邮寄至东京都港区新桥六丁目 8-1。本申请书搜集个人资料的目的是为处理入会申请及通过邮送、电子邮件、电话进行沟通联络。咨询电话：03-5422-1516。
(vi) I understand and undertake the annual payment of 5,000 Yen.
本人了解并同意一次性缴纳会费：5,000 日元* Only member have voting right at general meetings.
只有会员享有总会投票权。
Signature 署名：●Date 期日：Nominator 推荐人 (to be completed by the Nominator 推荐人记入)Name 姓名Tel 电话号码I, being JPIDA member, hereby propose the applicant.
本人现为日本独立董事协会之会员，现推荐上述申请人入会。
Signature 署名
●1.

2.
3.
4.

Date 期日Application document checklist 申请文件清单
A crossed cheque for membership fee.
会费支票Payable ：“The Japan Independent Director Association” .
支票抬头人：日本独立董事协会
Note: Unsuccessful applicants will be refunded with no interest payable.
注：如申请被拒绝，不支付利息A passport-sized photograph with name on the reverse (no staples or glue).
护照尺寸照片一张，背面书写姓名（请勿使用书钉或黏胶）。
A business card.
名片一张。
This duly completed and signed application form.
已填写完毕并签名的申请书

For Office Use Only协会职员专用

申请日期：

支票编号：

批准人：

批准日期：

会员编号：会员资格有效期：