www.urmpm.org

Annual Membership Registration Form

Union of Risk Management for Preventive Medicine

(URMPM)

TO:  URMPM Tokyo Office

4-36-2-103 Hongo, Bunkyoku, Tokyo, 113-0033, Japan.
c/o World Health Risk Management Center

(Email in English and Spanish) secr-office@umin.net

(Fax/Tel) +81-3-3817-6770

CHECK ONE.

I am sending about my

(  ) joining URMPM

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

(  ) leaving URMPM

WRITE YOUR PERSONAL INFORMATION.

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 ANNUAL 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: 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

Bank of Tokyo-Mitsubishi UFJ

Kamishakujii Branch, Tokyo, Japan.
Account: URMPM

Number 3990328.

List of international branches of Bank of Tokyo-Mitsubishi UFJ

*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’.