Application form for the ASNOS membership

Please fill in the information required below and send it to ASNOS office by
e-mail or fax. Please type clearly.

□ I would like to renew my membership.

□ I would like to make a new application.

Your name

Address

Institution

E-mail

Fax

The membership fee is \4,000 (JPY) and is valid for two years.

Please pay the fee by bank transfer to the account below.

Mitsubishi Tokyo UFJ Bank, Sagamihara Branch

Branch Number :259
Account Name: ANOS Wakakura Masato
Account Number :1521052

ASNOS office:
Address c/o Inouye Eye Hospital
4-3 Kanda Surugadai, Chiyoda-ku, Tokyo
101-0062 Japan
Telephone +81-3-3295-0911
Fax +81-3-3295-0917
E-mail miyajima-t@inouye-eye.or.jp