Human PSI Forum

Please send this form to the Forum Office via facsimile or mail by the deadline.

Name			Date
Contact	Address
	Phone	FAX	E-mail
Title of Presentation
Presentation Tools	Please check one items. Only OHP is available for Poster Oral Presentation. ____ I will use OHP Slide Video (VHS) PowerPoint (You should take your own computer) ____ I will not use any presentation tools.

Pay Options (Advance Order is needed.) Deadline of Order is the same of the deadline of manuscript.
Color Page Print	______ I order color printing ( _______ page) in my article.
Offprint	_____ I order offprint ( ______ copies) [ with a cover / without a cover ] of my article.
Sending Address	Address
	Phone	FAX	E-mail
Payment	_____ I pay my charge by Credit Card. _____ I pay may charge by International Postal Money Order.
Credit Card	[ VISA / Master Card ] Application Date M/D/Y _______/______/_______ Name _____________________________________________ Address __________________________________________ Amount ___________________________________________ Japanese Yen Phone ___________________________________________ Card Number ______________________________________ Expiry Date ______________________________________ Signature ________________________________________

* The money once paid will not be refunded under any circumstances.