Membership Form

Membership Category Membership CategoryRegular — $100Regular Spouse — $50Senior (over 65 years) — $60Senior Spouse — $40Student — $25Beiju (over 88 years) — FreeSupporting — $300Silver — $500Gold — $1,000Platinum — $2,000

Email Address

Title TitleMrMrsMsMiss

First Name

Initial

Last Name

漢字氏名 in Kanji (if applicable)

Mailing Address

City

State

ZIP

Business (if applicable)

Position

Business Address

Business Telephone

Business Email

Emergency Contact's Name (in the USA)

Emergency Contact's Telephone (in the USA)

Emergency Contact's Address (in the USA)

Emergency Contact's Name (in Japan, if applicable)

Emergency Contact's Telephone (in Japan)

Date of Birth

Special Gift ($)

Total Amount ($)

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