Visa Support Request Form

TO: Congress Secretariat of the 56th Annual Meeting of the Japanese Society of Neurology

c/o Congress Corporation

FAX:+81-3-5216-5552 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( ), 2015 to May( ),2015. ( Days)
Arrival at NARITA – HANEDA – NIIGATA Airport (circle one)
Flight No. ( )
Departure from NARITA – HANEDA – NIIGATA Airport (circle one)
Flight No. ( )

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( ), 2015 to May( ),2015. ( Days)
Arrival at NARITA – HANEDA – NIIGATA Airport (circle one)
Departure from NARITA – HANEDA – NIIGATA Airport (circle one)

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.