First Name:

Last Name:

E-Mail:

Address:

City:

Country:

Postal Code:

Tel area code: Tel:

Fax area code: Fax:

Nationality:
American Argentine Australian Austrian Belgian Brazilian British Canadian Chinese Danish Dutch Filipino Finnish French German Indian Indonesian Irish Italian Japanese Korean Malaysian Mexican New Zealander Norwegian Portuguese Singaporian South African Spanish Swedish Swiss Thai Welsh Other

Spouse's Nationality:
American Argentine Australian Austrian Belgian Brazilian British Canadian Chinese Danish Dutch Filipino Finnish French German Indian Indonesian Irish Italian Japanese Korean Malaysian Mexican New Zealander Norwegian Portuguese Singaporian South African Spanish Swedish Swiss Thai Welsh Other

Business (yours and/or spouse's) - optional:

Family members' names (and childrens' ages)

Include in Member Directory?
YES NO

What languages do you speak?
English Japanese Spanish German French
Chinese Korean
Other languages?

What countries have you lived in, and for how long?

What are you interested in learning during your stay in Japan?

What are your hobbies?

Would you be interested in helping CHIC with special events?
YES NO Not at this time.