Membership Application

Fill out the following form, and then e-mail the image file, fax or mail to:

E-mail: bunsikagaku-post(at)bunken.co.jp (Change "(at)" to "@")

FAX: +81-3-5227-8631

Address: Japan Society for Molecular Science

358-5 Yamabuki-cho, Shinjuku-ku, Tokyo 162-0801 JAPAN

Membership Application Form of Japan Society for Molecular Science

[Name]
      First:       Middle:       Family:

[Mailing Address]


      Phone:       FAX:       E-Mail:

[Membership Category (circle one)]
Regular: 4,000yen/year       Student: 2,000yen/year

For Application of Student Membership
University or College:

[Payment method]
Please charge _____ Japanese yen on my credit card for my JSMolSci membership fee (for year _____)

VISA or MASTER Number (No other credit cards accepted):

Exp. Date:

Signature of Card Holder: