URMPM Annual Membership Registration Form

TO: URMPM Tokyo Office

International Center for Urban Safety Engineering C404, Institute of Industrial Science

The University of Tokyo

4-6-1- Komaba Meguroku, Tokyo, 153-8505, Japan.
(Email in English and Spanish) secr-office@umin.ac.jp

(Fax) +81-3-5452-6432　

(Tel) +81-3-5452-6430

CHECK ONE.

I am sending about my

( ) joining URMPM

( ) changing personal information, as bellow. I am a member of URMPM.

( ) leaving URMPM

WRITE YOUR ERSONAL INFORMATIOM.

Name:

E-mail address (necessary):

Postal address:

Title:

Institution:

Country:

Introducer of your entry, if you have:

(Name)

(Institution, Country)

TWO WAYS OF PAYMENT OF AMMUNAL MEMBERSHIP FEE

(A) BY CREDIT CARD

Visa or Mastercard are acceptable

1) Card number:

2) Your name on the card:

3) Valid date:

4) Amount of payment: Japanese USD equivalent for 10,000 Japanese yen or 3,000 Japanese Yen (Please mark either one)*

*US$ equivalent to 10,000 Japanese Yen for the person from OECD countries; 3,000 Yen for the person from non-OECD countries. Those membership fees include your subscription of URMPM international medical journal of ‘Health’.

Don’t send your signature and the secret number of the card!

(B) BANKING

UFJ Bank

Kamishakujii Branch, Japan.
Account: URMPM

Number 3990328.

List of international branches of UFJ Bank

*US$ equivalent to 10,000 Japanese Yen for the person from OECD countries; 3,000 yen for the person from non-OECD countries. Those membership fees include your subscription of URMPM international medical journal of ‘Health’.