The 10th APACT Conference (APACT 2013)

REGISTRATION FORM

<Privacy Policy>

Your personal information will be handled based on the Privacy Policy ofAPACT2013.

Your registration by filling out this form will be considered as you have agreed with our privacy policy with 3 points described next page.

(1)Please fill in the form in English, (2) complete all lines hereunder marked with *, and (3) fill in one form per participant

*Title:Prof. Dr. Mr. Ms.

* Family Name:

* Given Name: Middle Name:

*Affiliation:

Department:

Position:

*Mailing Address Office Home

*Street:

City: State/Province/Region:

*Zip/Postal code: *Country:

*Phone: Fax:

*E-mail:

Registration Category / Early Registration
(On and before January 31, 2013) / Late Registration
(On and before July 31, 2013) / On-site Registration
(After August 1, 2013)
Delegate / JPY 50,000 / JPY 60,000 / JPY 80,000
Student* / JPY 8,000 / JPY 10,000 / JPY 15,000

Total: JPY

Credit Card:VISA MasterCard Diners Club American Express JCB

Card Number:

Expire Date: Month / YearCard Holder’s Name:

Bank Transfer: I (We) have remitted or will remit the above sum of JPY (total)on (date)

by the name of (remitter)through (name of bank) to:

*Bank handling charge should be borne by applicants.

*Welcome Party on August 18 / *Your dietary preferences
Will Attend Will NOT Attend / Normal Lacto-ovo-vegetarian Vegan
*The day(s) which you will need the Lunch Box
August 19 August 20 No, I do not need the Lunch Box
*Please incicate your age bracket / *Please indicate your gender
Under 25 26-35 36-45 46-55 56 and over / Male Female
*I am from the following sector
Government University NGO/NPO Hospital/Clinic Other
*I am a
Researcher Health professional Advocate Policy maker Other
*What is your primary interest?
Cessation Prevention Smoke-free environment Policy development Other
*How did you hear about the conference?
I have attended a previous APACT Direct mail Internet Word of mouth
Newsletter Journal Advertisement Other

The 10th APACT Conference (APACT 2013) - Privacy Policy
We, APACT Japan, are committed to protect the personal information of this conference's applicants. Your personal identifiable information (personal information) will be collected via this form only when you submit your registration for this conference (hereinafter the "Conference").

Without an applicant's consent, we (APACT Japan) will not use such information for the purposes other than operating and managing the Conference, responding to inquiries from applicants for the Conference, offering the Conference information and other future related conference to the applicants, preparing the participants' list to be distributed to the conference participants except for the personal information collected in connection with other websites.

For smooth operation of the Conference, we (APACT Japan) are entrusting the collection, storage, management and handling of personal information regarding the Conference to the following company who act as the Registration Office under a confidentiality agreement.

In case there is an error in your personal information collected for the Conference, please inform the Registration Office to have it corrected or deleted.

Please note that without providing the necessary information, we may be unable to process your submission.

Contact Information on managing personal information
ICS Convention Design, Inc.

Sales Department 4, Attn: Toru Kawaguchi (General Manager)
Chiyoda Bldg., 1-5-18 SarugakuchoChiyoda-ku, Tokyo 101-8449 Japan
Phone: +81-3-3219-3541

*ICS Convention Design -Privacy Policy:
Administrator of personal information collected for APACT 2013
Tadao ShimaoMD

President, APACT2013

1)I agree with the privacy policy shown above.

2)I agree APACT Japan will put your name, affiliation, e-mail and country on the participant's list

to be distributed to the conference participants.

3) I have NOT received any support from Tobacco Industry.

If you agree with the 3 points shown above, please fill in the Registration Form.

Your registration by filling out this form will be considered as you have agreed with these 3 points.

APACT 2013Registration Office
c/o ICS Convention Design, Inc.

Chiyoda Bldg. 1-5-18, Sarugaku-cho, Chiyoda-ku, Tokyo 101-8449 Japan
Tel: +81-3-3219-3600 Fax: +81-3-3219-3577, E-mail: