Registration form
International Workshop on Microspectroscopy of Quantum, Magnetic and Biological Nanostructures

Family Name: _________________  First Name: ______________  Middle initial: ____  Title: _____

Institution: _________________________________________________________________________________

Mailing Address: ____________________________________________________________________________

_____________________________________________   E-Mail: ____________________________________

Phone: ________________________  Fax: ________________________

Please check and fill appropriate blanks:

Registration fee:   5,000 Yen

            _______________Yen

Banquet:             5,000 Yen
( ) I will attend the banquet
( ) I will not attend the banquet

            _______________Yen

Accompanying person(s) at banquet: 5,000 Yen/person x_______(number of persons) = _______________Yen

              Family Name: _________________ First Name: ______________ Middle Initial: ____ Title: ____

              Family Name: _________________ First Name: ______________ Middle Initial: ____ Title: ____

Total amount: _______________Yen

Payment: (check one of the two ways)

( ) I have paid to the workshop bank account on (date:                ).

( ) Since I am an oversea participant I will pay at the workshop


Please check and fill appropriate blanks:

(  ) I will send an abstract for poster presentation within _____ days.

(  ) I have sent the abstract by e-mail on (date:                      ).

              The name of the 1st author is : ____________________. 

              The title of the paper is:

              __________________________________________________________________________________________________________