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

Company Membership Application Form
Company Membership Type Applied For 会员类型：⃞Company Member 企业会员*●Company Particulars

公司信息Company Name 企业名称

Place of Registration 企业注册地Company Address企业所在地Post Code 邮政编码Business Registration No. 企业法人号码

Co Legal Status (by inserting ✓in the box) 企业类型 (在方格内标注「✓」)⃞ Listed co 上市公司

⃞ Private limited co 私人有限公司⃞ Partnership 合伙企业⃞ Statutory or public or non-profit organisations 特殊法人、公营企业或公益法人⃞ Sole proprietorship 独资经营⃞ Subsidiary of overseas co 海外机构之附属机构
Others 其他：
Company Principal Activities 企业主营业务Company Website 企业网址
Office Tel. No. 企业电话Fax No. 企业传真

(Please use on separate sheets if necessary. 如有需要请另页书写)●Company Representatives 企业会员联络人Company Representatives企业联络人Name
姓名Position职务Tel.
电话E-mail电子邮件●●

Chief Contact Person
第一联络人
Second Contact Person
第二联络人
Third Contact Person
第三联络人●Declaration

声明(i) We hereby declare that the information given in this application form is true, correct and not misleading.
本企业声明，本申请表所填信息真实准确、没有误导。
(ii) We hereby apply for membership of The Japan Independent Director Association (the “Association”) andundertake to abide by the Association’s Articles of Association as amended from time to time.
本企业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》。
(iii) We 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 thefollowing option by inserting ü in the box: 本企业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。
We DO NOT wish to receive above communications from the Association.
⃞本企业不希望接收以上协会资讯(iv) We have read and understand the following declaration regarding data collection:
本企业已阅读并了解下列关于相关资料的搜集说明。
Data subjects who may opt out from receiving communications may notify the Association in writing. Data
subjects have a right of access and correction regarding their respective personal data and may require theAssociation to cease to use the data. Requests can be directed to the Association by post at 6-8-1 Shinbashi
Minato-ku Tokyo. Data collected by this document will be used to process application for membership andfacilitate communications by post, email and telephone. 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。本申请书搜集相关资料的目的是为处
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。
(v) We understand and undertake the annual payment of 50,000Yen company membership fee
本企业了解并同意每年缴纳会费：50,000 日元* Only member have voting right at general meetings.
只有会员享有总会投票权。

Company Chop 企业盖章：

Date 期日：

Authorised Person 授权人：Position 职务：●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

Date 期日●Application document checklist申请文件清单

1. 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
2. A copy of the applicant’s certificate of incorporation or equivalent document.
企业注册证明书或同等文件副本。
3. 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：