confirm Please confirm your registration information below. *Please check the following to continue with the registration. I understand and consent to Handling of Personal Information I understand and consent to the MVN Membership Policy Name* Surname Middle Name Given Name Date of Birth* Year: 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 Month: 1 2 3 4 5 6 7 8 9 10 11 12 Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Age: Automatic calculation Gender* Male Female Address*Japan Postal Code Prefecture Address Building/Apt.# Phone Number * Email Address* Confirm Email Address* *Please input the same email address as above. Height (cm)* Weight (kg)* BMI Automatic calculation Nationality* Ethnicity* --Please select-- White/Caucasian Black Asian Other In case of Other, please specify: Type of Visa* (Eg. Specialist in Humanities, Student, Spousal) Visa Expiration Date* N/A Year : 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Month: 1 2 3 4 5 6 7 8 9 10 11 12 Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Medical Conditions I am healthy and do not have any of the following conditions. *Please check all that apply. Have type two diabetes. Have high blood pressure (maximum pressure 140 and over, or minimum pressure 90 and under) Have liver dysfunction Have kidney dysfunction Have hyperlipidemia Have atopic dermatitis (eczema etc.) Have a condition other than those listed above *Note that if you have one of the conditions above, we may contact you to request additional information about the diagnosis, and other details. Medical History (Illnesses/conditions you have had, injuries that have required hospitalization or surgery etc.) No.1 Period of onset (approximate age) Details Current condition Monitoring symptoms Fully recovered Stopped treatment Other No.2 Period of onset (approximate age) Details Current condition Monitoring symptoms Fully recovered Stopped treatment Other If you were introduced by someone, please provide their name. Confirm
