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ACPM 2017 Symposium on Atmospheric Chemistry and Physics at Mountain Sites

7-10 November 2017 Shizuoka, Japan

Registration Form

After filling out the following form, please click "Confirm" to submit it.
Fields marked with an * are required.

Name and Affiliation
* Title
* First Name
* Last Name
Middle Name
* Only the first letter of names should be uppercase (e.g. Albert, Einstein)
Name as it should appear on a badge
* Affiliation
Contact Details
* Contact
* Street
* City
* State/Province/Prefecture
* Country
* Zip/Postal Code
* Phone
+ e.g. 81-11-111-1111
+ e.g. 81-11-111-2222
* E-mail address
(Retype the E-mail address for verification.)
  Early Registration
(Before or on July 31, 2017)
(Before or on August 7, 2017)
Late Registration
(On or after August 1, 2017)
(On or after August 8, 2017)
* Registration

Accompanying person conference banquet JPY 10,000/person:  person(s) JPY 10,000/person:  person(s)
* Dietary Restrictions       
If, Yes
One-day trip
* One-day trip Visiting an old shrine and a water-rich spring and viewing the whole Mt. Fuji.
Date : 07 Nov., 2017
Participation fee : JPY 5,000 / person
[Notes] If there are not enough participants, there is a possibility that one-day trip will be cancelled.
* Accommodation       
Accompanying person(s) person(s)
   Name of accompanying person(s)   
   Name of accompanying person(s)   
Date Check in     
Check out   
Smoking room    
If you wish to stay over 4 people, please contact us separately.
Registration Fee JPY
One-day trip Fee JPY
Accomodation Fee JPY
Total Amount JPY
* Payment Bank Transfer only.

Bank Transferを選択し、下記クレジット情報は空欄のまま、確認画面へお進みください。なお、振込手数料は参加者の方のご負担となりますのでご了承ください。
Credit Card visamaster
  Please note that your credit card will be charged by our official credit card service provider called "CLEAR MEMBERS." The name "CLEAR MEMBERS," instead of ACPM2017, will appear on your credit card statement. Please also note that it could take up to 10 days before the transaction being processed.
Credit Card Number - - -
Security Code
Expiration (MM/YYYY)
Card Holder's Name (as it appears on the card)