Application Form for PCCIJ Membership

The under-mentioned Company/Individual herewith applies to become a member. (please check the one which applies) *

Regular Member (Company) *annual fee：￥120,000-
Regular Member (Individual) *annual fee：￥20,000-
Regular Member(Student) *annual fee：￥10,000-
Regular Member (Overseas) *annual fee：€500- or PLN 2,000-

Applicant (Company name) *

※If you want to join as a Regular member (Company) , please put the name of your company, otherwise please put your name.

Name of the representative of the company

※Please fill in if you would like to join as a Regular member (Company) .

Position of the representative

※Please fill in if you would like to join as a Regular member (Company) .

Individual or Headquarter's address

※ If you want to join as a Regular member (Company) , please put the Headquarter’s address, otherwise please put your individual address.

Tel. *

Fax

URL

※Please fill in if you would like to join as a Regular member (Company) .

Email *

Name of the person in charge

※If you want to join as a Regular member (Company) and the contact person will be someone other than the corporate representative, please fill in .

Division & Position of the person in charge

※If you want to join as a Regular member (Company) and the contact person will be someone other than the corporate representative, please fill in .

Tel

※If you want to join as a Regular member (Company) and the contact person will be someone other than the corporate representative, please fill in .

Business Type

※Please fill in if you would like to join as a Regular member (Company) .

Profession

※Please fill in if you would like to join not as a Regular member (Company) .

Introduced by

Date *

Do you want to put member information on PCCIJ's website and in other publications? Note: PCCIJ reserves the rights to decide on whether or not to publish the information.

※If yes, we will contact you to confirm the details.