Please send the completed and signed form (Page 1-2 required. Page 3 optional) to ACCJ

by email or fax (03) 3433-8454. Fields marked with an asterisk (*) are required.

Member Recommendation
Please indicate the name of an ACCJ member who introduced the ACCJ to you (if applicable).
Member name:
Reasons for joining (goals and aspirations) e.g., Advocacy, Networking, Information
How did you hear about us? (Please check all that apply)
Web search Word of mouth (friends/family/colleagues) ACCJ hosted/sponsored events
SNS - Please check: Facebook Twitter LinkedIn YouTube
Advertisement/News story - Please specify (i.e. newspaper/magazine):
ACCJ Journal Other:
Status of Residence in Japan* (Please check one)
As an Individual Member:
I am a Japanese citizen.
I am a permanent resident of Japan.
I hold a current resident visa to live, work or study in Japan.
Member Data
Please write your name here as you would like it to appear on ACCJ printed materials.
First name*: / Middle name:
Last name*: / Suffix (Jr./Sr./III):
Title (please check one)*: Mr. Ms. Dr. Other ()
Gender*: Male Female / Citizenship*:
Date of birth (mm/dd/yy):
Name of last school attended:
Degree (list highest degree earned): / Country:
English ability (please check one): fluent good minimal none
Japanese ability (please check one): fluent good minimal none
Home address (optional)
Bldg. name:
Street number: / Street /Area/ Ward:
City: / Prefecture/State:
Country: / Postal code:
Home phone: / Home fax:
Company name:
Title/Department:
Website: / General phone:
Mailing address*
Bldg. name:
Street number: / Street /Area/ Ward:
City: / Prefecture/State:
Country: / Postal code:
Office Phone: / Office Fax:
Alternate contact number: / Cellular Phone Fax
Email address for receiving ACCJ communications*:
Email address for Directory listing (if different from above):
Personal Data Private Opt-in/Opt-out (Failure to make any selections will default all choices as no.)
Do you want to show your direct contact information (title, mailing address, email address) to members in the Member Database in the member-only website?
Yes No
Note: The setting above will be reflected in the Member Database, but not in the annual Membership Directory. The annual Membership Directory is compiled yearly between November and December and is distributed in the spring of the following year. Since appearing in and receiving the Directory are considered to be important benefits of ACCJ membership, it is assumed that all members will want to have their contact information appear in the Directory. You will be contacted at that time to confirm your listing for the Directory.
Mailing Label Preferences (Failure to make any selections will default all choices as no.)
The ACCJ sells adhesive mailing labels drawn from our member database (name, title, company name and mailing address) for both member and non-member purchase.
Would you like to be listed in ACCJ mailing labels and receive mailings?
Yes No
Please go to to see ACCJ Privacy Policy.
Please note that the ACCJ may share your name, title, company name and mailing address with vendors and strategic partners for providing you with membership services.
Pursuant to the requirements of the ACCJ Constitution and Bylaws, I hereby certify as follows (please check the box or provide information below)*:
Except as detailed below, I have never been (i) convicted of a criminal offense; (ii) adjudicated bankrupt or insolvent; or (iii) disqualified or disbarred from membership of, or subject to any probation or disciplinary sanctions by, any professional, regulatory or other body or authority, that prevents me from performing any professional services.
Note: The ACCJ Constitution requires that every two years, we confirm the eligibility of your Individual Membership. The ACCJ Membership Department will be contacting you everytwo years to re-certify your status (above questions and status of residency).
Agreement [1)]
The undersigned, if and when accepted as a member, agrees to be bound by the Constitution and Bylaws of the Chamber. Further, the undersigned acknowledges having read and understood the ACCJ Privacy Policy as provided in this packet. As set forth in the Constitution and Bylaws, the undersigned also agrees that membership dues shall be paid annually, and fees, if any, shall be paid monthly upon receipt of an invoice from the ACCJ.
Signature*: / Date (mm/dd/yy):
Note: Unsigned applications will not be accepted.

Industry Index Selections (Optional)

Please select the industry indexes that describe your company/business (maximum of five industry indexes). Your selected industries will appear in the ACCJ Membership Directories.

Accounting and Auditors / Healthcare, Pharmaceuticals, and Medical Devices
Advertising and Marketing / Hotels, Hospitality, and Recreation
Airline/Aviation Services and Supplies / Human Resources and Executive Search
Architecture and Interior Design / Import, Export, and Trade
Art / Industrial Processing and Manufacturing
Attorneys and Legal Services / Insurance Services
Automobile Parts and Services / Machinery, Equipment, and Instruments
Banking and Financial Services / Market Research
Basic Materials (Agricultural, Chemical, Gas, Metals, Oil) / Movers and Relocation
Business Centers and Serviced Offices / News and Multimedia
Clinics and Hospitals / Organizations and Associations
Computer/IT/Internet-Related Products and Services / Other Services
Construction and Engineering / Public Relations
Consulting - Business and Management / Publishers/Editing/Graphic Design/Printing
Consulting - Market Entry / Real Estate
Consulting - Other / Restaurants
Consumer Goods and Retail Services / Schools
Electronics and Electrical Products / State Representatives and Government Offices
Energy / Tax Consulting
Environment / Training and Development
Events and Entertainment / Translation and Interpretation Services
Food and Beverage / Transportation and Logistics
Freight Forwarders and Couriers / Travel and Tourism
Government Relations / Visa and Immigration Services

1

RVSD: 2017.01

[1)]ACCJ memberships renew automatically on the annual anniversary of the date on which you became a member. The ACCJ bills annual membership dues three months before your new membership cycle begins to give you ample time to pay or to let us know before your current membership expires if for any reason you do not want your membership to automatically renew.

Bills still unpaid two months after the due date are deemed delinquent and may lead to loss of membership. If you wish to resign or cancel your membership, you must give written notice to the ACCJ Executive Director at least one calendar month beforehand. Until your written notice is received, your membership remains active and your membership dues will continue to accrue for the prorated month(s).