www.urmpm.org

Annual Membership Registration Form

Union of Risk Management for Preventive Medicine

(URMPM)

TO:  URMPM Tokyo Office

4-36-2-103 Hongo, Bunkyoku, Tokyo, 113-0033, Japan.
c/o World Health Risk Management Center

(Email in English and Spanish) secr-office@umin.net

(Fax/Tel) +81-3-3817-6770

CHECK ONE.

I am sending about my

(  ) joining URMPM

(  ) changing personal information, as bellow.  I am a member of URMPM.

(  ) leaving URMPM

WRITE YOUR PERSONAL INFORMATION.

Name:

E-mail address (necessary):

Postal address:

Title:

Institution:

Country:

Introducer of your entry, if you have: 

    (Name)              

    (Institution, Country)

TWO WAYS OF PAYMENT OF ANNUAL MEMBERSHIP FEE

(A) BY CREDIT CARD

 Visa or Mastercard are acceptable

1) Card number:

2) Your name on the card:

3) Valid date:

4) Amount of payment: ( ) 100 US$, or ( ) 30 US$ (Please mark either one)*

*100 US$ for a person from OECD countries; 30 US$ for a person from non-OECD countries. Those membership fees include your subscription of URMPM international medical journal of ‘Journal of Medical Safety’.

Don’t send your signature and the secret number of the card!

OECD : http://www.oecd.org/

(B) BANKING

Bank of Tokyo-Mitsubishi UFJ

Kamishakujii Branch, Tokyo, Japan.
Account: URMPM

Number 3990328.

List of international branches of Bank of Tokyo-Mitsubishi UFJ

*100 US$ for a person from OECD countries; 30 US$ for a person from non-OECD countries. Those membership fees include your subscription of URMPM international medical journal of ‘Journal of Medical Safety’.