Asia Pacific Software Engineering Conference '99 : Registration Form 
 

  Full Name : __________________________________________  

  Name as preferred on badge :  ____________________________  
 
  Title :   Ms.  Mr.  Dr.  Prof. 

  Affiliation : ____________________________________________
 
  Address : ________________________________________________
 
            ________________________________________________  
 
  Country/Region :  ________________        Post/Zip Code :  _________________
 
  Telephone : ________________________  Fax :  _______________________

  E-mail :  ___________________________ 
 
  Paper ID : _________________
  (If you are the speaker of the accepted paper, please fill your paper ID). 

  Registration Fee : ____________________ Yen 

  IPSJ (for Japanese only) number or Student ID Number : ______________________ 
  (If you are a IPSJ member or a student, please enter the ID) 

  Extra Banquet Fee : @5000 Yen  X   ___________ = ______________ Yen 



Total Ammount :  ___________________ Yen

Payment Method :  Bank Transfer     Check       Credit Card 

Credit Card Information

 Credit Card :          Master Card       Visa     

 Card Number :          ______________________________________   

 Card Holder's Name:    ______________________________________   

 Card Holder's Address: ______________________________________   

                        ______________________________________ 

 Expiration Date :      ______________________________________ 

 Total Amount:          ______________________________________ Yen 

 Signature : _______________________________ Date :_________________