Please make sure fill the following information even we have on our file.

Mr./Mrs./Ms:    First Name___________________ Last Name:__________________________

(Spouse) Mr./Mrs./Ms:    First Name______________ Last Name:_______________________

Company Name:_______________________________________________________________

If student membership, please list name of your school.______________________________

Address______________________________________________________________________

Town: ________________________________________ State:_____ Zip Code:____________

Home Phone:________________ Cell Phone:__________________ Work Phone__________

E-Mail _______________________________________________________________________

We are going to distribute our membership list. Please answer the following.

                   [     ]   I do not want my address printed.

                   [     ]   I do not want my home phone number printed.

                   [     ]   I do not want my cell phone number printed.

                   [     ]   I do not want my Email printed.

                   [     ]   I do not want my work address printed.

                   [     ]   I do not want my work phone number printed.

Which activities would you like to help (Please check at least one)

[   ] Membership            [   ] Fund Raising           [   ] Newsletter   [   ] Web          [   ] Bus Trip

[   ] Nihongo Night          [   ] Xmas Party            [   ] New Years Party      [   ] Education            

[   ] Summer / Fall Picnic     [   ] Hospitality         [   ] Special Activities     [   ] Other

I would like to make an additional contribution :              $________

                       Total with membership enclosed :              $___________

Please complete the form above and send with a check payable to JSC to the following address:

Japan Society of Connecticut

(Japan-Society of Connecticut)

PO Box 252

Plainville, CT  06062  USA