Date: ______________
Application for Membership
in the
Society for the History of Western Learning in Japan

Name, Given Name: _____________________________________________________
          ZIP Code: __________________
Adress (Home):_________________________________________________________
          TEL: __________________   FAX:  __________________   
Employer / Educational Institution: __________________________________________
          ZIP Code: __________________
Adress : _________________________________________________________
          TEL: _____________________   FAX:  ____________________
          EMAIL: ________________________________________________
Which adress should be used as contact adress?
          Home         Employer / Educational Institution
Fields of Interest / Research / Studies: