The Asian Pacific Association for the Study of the Liver [APASL]

APASL Membership Application

INSTRUCTIONS


  • Input your information to this form.
  • All personal information sent for membership application is confidential and secured by a high security encrypted format (SSL format).
Registration Information *: Required.
First Name *
Middle Name
Last Name *
Institution *
Department
Title *
Sex *
Date of Birth *
Country *
City *
Postal Code *
Address1 *
Address2
E-mail 1 *
E-mail 2
Phone 1 *
Phone 2
Fax
I agree to receive regular alerts of Hepatology International.  -----------> 
Membership And / Or Subscription Fee
APASL Membership fee (US$100/year)
Subscription : Hepatology International (4 Issues+Supplements) (US$100/year)
Donation to APASL US$
Method of Payment * Please choose either a credit or a bank transfer.

Please input card information, when a payment method is a credit card.

Kind of credit card
Credit card number ex.1234-1234-1234-1234
Name of card holder
Expiration date (mm/yyyy)

If you choose Bank Transfer, instead of Credit Card payment, Bank Charge (US$25) is needed as a handling fee in addition to membership and/or Hepatology International subscription fees.

Bank Name Bank of Tokyo-Mitsubishi UFJ
Branch Name Shinjuku Branch
Account Number 0028011
Account Name APASL
Bank Address 3-4-8, Shinjuku, Shinjuku-ku, Tokyo, 160-0022, Japan
SWIFT CODE BOTKJPJT