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					                           The 58th Annual Meeting of JSA &
                     The 2nd SOAP JSA Obstetric Anesthesia Meeting
  * Please complete the form and return to (the secretariat)via either fax (+81-78-306-5946) or e-mail
  (fuji@anesth.or.jp)
  All information below is required in order to process the documents for your visa application. We will not be
  able to issue the documents if any of the information below is missing.
                                 VISA APPLICATION FORM
                                                                                            (Please type or print)

  Personal Data
        Applicant name:
                             *Exactly as printed on your passport


                             First                         Middle                       Family
                                                                                        Chinese Citizens are requested to write
                                                                                        down their names aloso in Chinese
                             姓                             名                            characters.

             Occupation:                                   Congress Registration#

Institution / Department:

                 Address:
                             *The documents will be sent to the address printed above
                      Tel:                                                      Fax:

                  E-mail:

            Date of birth:                                            Place of birth:
                               (Day) / (Month) / (Year)
              Nationality:                                                      Sex:

             Passport No:


  Travel Itinerary
       Arriving to Japan
              Flight Date:
        Departing Airport:                                          Arriving Airport
          Flight Number                                             Departure Time:

              Flight Date:
       Departing Airport                                            Arriving Airport
         Flight Number:                                             Departure Time:

              Flight Date:
       Departing Airport                                            Arriving Airport
         Flight Number:                                             Departure Time:
**Please make sure you list all of the flights you are taking from your country to Kobe/Osaka/Tokyo.
Do not omit any transit flights.**

Departing from Japan
            Flight Date:
    Departing Airport:                                            Arriving Airport
         Flight Number                                            Departure Time:


            Flight Date:
     Departing Airport                                            Arriving Airport
        Flight Number:                                            Departure Time:


            Flight Date:
     Departing Airport                                            Arriving Airport
        Flight Number:                                            Departure Time:


**Please make sure you list all of the flights you are taking from Kobe/Osaka/Tokyo to your country.
Do not omit any transit flights.**


       Other Schecules




**Please list all itinerary if you are traveling within Japan before/after the conference. (Please note the
itinerary must include the dates, the transportation and the name and/or address of stay)**


Accommodation
          Name of hotel


                Address
                   Tel:
          Name of hotel
                           *If you stay more than one hotel, please fill in.

                Address
                   Tel:

Accompanying persons
          Number of                                       Please complete another application for each accompanying
accompanying persons                                      person
To faciliate your visa application, please complete the following declarations. Thank you for your cooperation.
I certify that the satatements made by me in this form are true and correct to the best of my knowledge.

     I agree                     I do not agree

     A) To obey Japanese law during my stay in Japan.
     B) To report on my stay in Japan to the chairman of the meeting if requested.
     C) To report any changes in the schedule of my stay to the chairman of the meeting, and to follow his instruction.
     D) Not to engage in any activities unrelated to the purpose of my visit.
     E) To return to my home country immediately after the meeting.
     F) To declare that I am healthy and free of any contagious disease.
     G) To be responsible for all necessary expenses regarding , but not limit to, travel and accomodation.

                                                                                Name:
                                                                                 Date:


We would like to emphasize that the above information is absolutely necessary and we cannot prepare the necessary
documents unless you complete all sections of the form.
We look forward to receiving the information at your earliest convenience.

Secretariat
Japanese Society of Anesthesiologist
Kobe KIMEC Center Building 3F
1-5-2 Minatojima-Minamimachi,
Chuo-ku, Kobe 650-0047 Japan
Tel:+81-50-8883-7008
Fax: +81-78-306-5946
E-mail : ino@anesth.or.jp

				
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posted:8/22/2012
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