入力内容保存/読込

JSPA Regular membership/Application form

Complete the form below and press the confirm button.
Namerequired
Last name 
First name 
Genderrequired
Date of Birthrequired
 Year  Month  Date 
Mail Addressrequired

Please re-enter to confirm.
Medical license(Acupuncturist/Moxibustionist/Doctor/etc.)required

Please enter your medical qualification.Multiple answers allowed.
Work place/Affiliation(Multiple answers allowed)required

If not,enter "None"
Registered addressrequired

Please enter zip/postal code,street address,town/city,Country.
The registered address will be printed on the member list of JSPA.
(Whether to publish can be selected from the question below.)
Delivery address

If you wish to receive postal delivery from JSPA other than the registered address,please enter the delivery address.
Please enter zip/postal code,street address,town/city,Country.
Contact phone numberrequired
 Country code   -  - 
Mobile phone allowed
FAX Number
 Country code   -  - 
Allow or not to publish your name in the member list of JSPA.required
Message if any