日本遺伝子細胞治療学会

Membership classification information

Request date

2024.04.26

Membership classification*

Basic information

Name

Last name

First name

Name (Roman alphabet)

Last name

First name

Prefix

Birthday

Gender

Male

Female

Prefer not to disclose

E-MAIL*

E-MAIL(For confirmation)*

Magazine Shipping address*

office

Home

Billing address*

office

Home

Company　address

Domestic-overseas

Domestic

Abroad

Office name

Office name(KANA)

Affiliation

Duty

Zip*

Address

Please do not enter the prefecture name ・work name in the address

You can enter up to 3 lines.

Phone

Please put "-"

Extension

Ｆacsimile

Please put "-"

Mobile phone

Please put "-"

E-MAIL

Home address

Domestic-overseas

Domestic

Abroad

Zip*

Address

Please do not enter the prefecture name in the address

You can enter up to 3 lines.

Phone

Please put "-"

Mobile phone

Please put "-"

Ｆacsimile

Please put "-"

E-MAIL

etc.

誓約書

誓約書のPDF*

Student ID

有効期限の記載面も添付してください。アップロードできるファイルは1つだけです。

Copy of student ID*

Recommender(Regular Member)

本学会の評議会員、名誉会員からのご推薦がある方は以下に推薦者名をご記入下さい

full name of the recommender

Recommender(Student menber)

入会をご推薦いただいた指導教官のお名前をご記入下さい（当学会の会員・非会員を問いません）

full name of the recommender*

紹介者（協賛企業）

本学会の評議会員、名誉会員からの紹介の場合、以下に紹介者の方の氏名をご記入下さい。

紹介者氏名

Application entry