HYP2004 REGISTRATION & HOTEL RESERVATION FORM

Name Please check    Prof.    Dr.    Mr.    Ms.      sex   Male    Female
Family Name       Given Name 
Institution
Position
Mailing Address Please check    Office    Home

Country 
e-mail
Tel
Fax

Expected arrival date Sept. , 2004 Expected departure date Sept. , 2004


Registration Fee & Banquet Fee (Please fill "1" in the appropriate box)
Category On or before July 15 After July 15
Regular Participant (Non-student)   JPY 11,000-    JPY 13,000-
Student   JPY 5,000-    JPY 6,000-
Banquet for Regular Participant (Non-student)   JPY 5,000-    JPY 5,000-
Banquet for Student   JPY 3,000-    JPY 3,000-
Total: JPY     

Hotel Accommodations
Hotel code, 1st choice
Hotel code, 2nd choice
Hotel code, 3rd choice
Number of rooms  room(s)
Check-in date Sept.   , 2004
Number of nights  night(s)
If shared accommodation is required, please fill in your room partner's name:
Please check    Prof.    Dr.    Mr.    Ms.           sex   Male    Female
Family Name        Given Name 


Special Request/Comments, if any
(If you are Young Researcher's Grant supported, please comment it here)



Payment
 Credit Card    Please charge the above total to my credit card
Type of Card:  VISA       Master Card       American Express       Diners
Card Number:
Expiration Date: (Month)   (Year) 
Holder's Name:
Holder's Signature:

 Bank Transfer    (For overseas transfer, you need to add additional 3,000 JPY for handling charge.)
I have remitted amount of JPY   on   (date)

 Pay on-site

I hereby understand and agree to the conditions set forth in this application form and circular.

Date:
Signature:

Send the form by fax (+81-6-6634-1185) or postal mail to HYP2004 Desk of Kinki Nippon Tourist.
Deadline : Aug. 13 (Fri.), 2004


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