Visa Support Request Form

TO: Secretariat of the 55th Annual Meeting of the Japanese Society of Neurology

c/o Congress Corporation

FAX:+81-92-716-7143 E-mail:

**Please type your information and send it to the secretariat by e-mail.

1 / Passport No.
2 / Nationality
3 / Title / ( ) Prof. ( ) Dr. ( ) Mr. ( )Ms.
4 / Name (alphabetized)
*As appears on your passport / Family Name / Given Name / Middle Name
Chinese Character
(if applicable)
5 / Affiliation
6 / Office Address / Address (Street, City, Province)
Country / Postal Code
Phone / Fax
E-mail
7 / Sex / ( ) Male ( ) Female
8 / Date of Birth / ( Day/Month/Year i.e. 01/01/1975)
9 / Occupation
10 / Accompanying person / ( ) Male ( ) Female / Title
Date of Birth(Day/Month/Year)
Nationality
Occupation
Family Name / Given Name / Middle Name
Chinese Character (if applicable)
11 / Mailing Address / **Please send visa application materials to;
( ) Office Address above.
( ) Other Address
Address:
Phone:
12 / Your Itinerary / ** I will stay in Japan
from May ( ), 2014 to May ( ), 2014. ( Days)
Flight Information to Fukuoka, Japan i.e.JL007
Flight Information from Fukuoka, Japan i.e. SQ443

Please list your entire itinerary while in Japan (including tentative one).

If your stay extends beyond the meeting, also indicate the purpose of the stay.

Date / Itinerary / Hotel / Purpose
1
2
3
4
5

If your accompanying person has the same itinerary as you, you may skip this section.

Accompanying person’s Itinerary / ** He / She will stay in Japan
from May ( ), 2014 to May ( ), 2014. ( Days)
Flight Information to Fukoka, Japan i.e.JL007
Flight Information from Fukuoka, Japan i.e. SQ443

Please list your entire itinerary while in Japan (including tentative one).

If your stay extends beyond the meeting, also indicate the purpose of the stay.

Date / Itinerary / Hotel / Purpose
1
2
3
4
5

Please note that it is absolutely necessary that you provide us with correct information in order to expedite the visa process.

Once again, it takes 4-6 weeks to process each application so your prompt action is requested.