第81回日本大腸肛門病学会学術集会
ご登録者情報の入力 / Enter Registrant’s Information

Please enter the required information and click the “Proceed to Confirmation” button.

Fields marked with * are mandatory.
参加登録者情報の入力 / Enter Your Information
居住地 / Residence*
国内：以下日本語で入力してください。　Overseas：Please enter the following information in English.
Name*
[First Name]：
[Middle Initial] (Optional)：
[Last Name]：
This information will be printed on the name tag.
Title*
所属先名 / Name of Affiliation*
例東京大学医学部医療情報学科 / Department of Biomedical Informatics, Graduate School of Medicine, The University of Tokyo
ネームカード印字用所属先名 /
Affiliation Name for Name Card Printing*		 全角15文字以内 / Within 30 characters
役職 / Position
連絡先 / Contact*
Street / Building*
Town*
City*
State*
Zip code / Postal code*
Country / Region*
TEL*
Emergency Contact Phone Number*
電子メールアドレス / E-mail*
（確認用 / for confirmation）
※Please do not use a mobile carrier email address to register.
今回の学会期間中（前後も含む）に宿泊をされますでしょうか。 /
Will you be reserving accommodation during the conference period (including the days before and after)?*
To apply for a grant from the Nagasaki International Tourism and Convention Association, our meeting is required to submit a report on the accommodation details of conference participants.
We kindly ask for your cooperation in completing the survey below.
(If your hotel or number of nights has not yet been finalized, providing your planned arrangements is acceptable.)
性別 / Gender*
年代 / Age group*
演題登録番号 / Abstract Registration Number 演題登録者入力欄/Field for Abstract Submitter
お申込み内容 / Application details
参加登録区分 / Registration Category*
¥ 18,000
証明書または学生証のアップロード*

*Only files with the extension "pdf/jpeg/jpg/png" can be uploaded.
*The maximum file size of each graphic/tables is "20MB".

領収書 宛名/Receipt Addressee*
アンケート / Questionary
参加方法 / Onsite and / or Online Style of participation*
ランチョンセミナー参加予定 / Participation in the luncheon seminar*
Which type of lunch box would you prefer?*
We may not be able to provide lunch boxes other than the regular type.
長崎までの交通手段 / Transportation to Nagasaki*
個人情報取り扱いの同意 / Consent to handling personal information
このフォームで頂戴する個人情報の取り扱いについて
Handling of personal information received in this form
  1. Name of the Business Operator
    Convention Linkage, Inc.
  2. Name or Position, Affiliation, and Contact Information of the Personal Information Protection Administrator (or their representative)
    Affiliation:：IT Business Division, Director
    Contact：+81-3-3263-8686
  3. Purpose of Use of Personal Information
    To respond to inquiries, including contacting the individual concerned.
  4. Outsourcing of Personal Information Processing
    In the course of conducting our business, we may outsource the handling of personal information to external parties, but only to the extent necessary for the purposes of use described above. In such cases, we select contractors that maintain a high standard of personal information protection, enter into agreements concerning the proper management and confidentiality of personal information, and ensure that appropriate management measures are implemented.
  5. Requests for Disclosure, etc. of Personal Information
    You may request that we disclose or otherwise handle your personal information (including notification of the purpose of use, disclosure, correction, addition, or deletion of information, suspension or erasure of use, or suspension of provision to third parties) by contacting our inquiry desk listed below. Upon verifying your identity, we will respond to your request within a reasonable period.

    【Contact】
    2 Sanbancho, Chiyoda-ku, Tokyo 102-0075, Japan
    TEL: +81-3-3263-8686　FAX: +81-3-3263-8687
    MAIL：cl1@c-linkage.co.jpOffice
    Hours: 9:00–18:00

  6. Voluntary Provision of Personal Information
    Providing your personal information to us is voluntary. However, if you do not provide the required information, we may be unable to provide an appropriate response or service.
お支払い方法等 / Payment methods
お支払い金額 / Payment amount
お支払い方法 / Payment method*
カード会社 / Credit card company*
カード番号 / Credit card number*  
*Don’t include hyphens. If using Amex, add ‘0’ before the number to make it 16 digit.
ex. Amex 3123-456789-12345, becomes 0312345678912345.
名義 / Name on the Credit card*
有効期限 / expiration date* 月(Month)／ 年(Year)
セキュリティコード / Security Code*
* A 3- or 4-digit number printed on the back or front of your credit card