Application Form for the Membership of Japanese Society for the Study of Xenobiotics
* Required
Type of Membership/Mailing Address
*Types of Membership Regular Member (Fee: JP \8,000)
Student Member (Fee: JP \4,000)
*Mailing Address Home Office
Name/ Date of Birth / Gender
*Full Name
*Gender Male Female
*Date of Birth
Home Address
Street Address
City
State
Country
Zip code
Telephone / Fax /
Email address
Office or Lab Address
Organization
Street Address
City
State
Country
Zip code
Telephone / Fax /
Email address
Education
*Final Education/ graduation year /
Degree
Current Position
Special Field of Interest
Payment
1 I enclose a bank draft made payable to Business Center for Academic Societies Japan.
2

I will remit/have remitted the above amount
on (date) through my bank to the account of Nihon Yakubutsu Dotai Gakkai Kaicho Inui Kenichi, A/C No. 218-8719913, Swift SMBCJPJT Sumitomo Mitsui Banking Corporation, Kojimachi Branch, Tokyo

3 I agree to pay the above amount by my credit card.
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