Talk with Ms. Mary Sjostrom

Talk with Ms. Mary Sjostrom
Mayor of Quesnel, British Columbia, Canada
7:00 pm - 9:00 pm on Friday, June 22, 2012

Application Form
(*): required item

1. Name (*):

2. Name in Japanese

3. Age:

4. Gender:

Female Male Not Answer

5. Company:

6. Occupation:

7. Prefecture of residence:

8. E-MAIL:

PC email address:
PC email address (to receive confirmation)

* Upon receipt of your application, the confirmation notice will be sent by email. If you do
not receive it within 30 minutes, please notify us by email at omokare.open@ewoman.co.jp.

9. Emergency contact number:

Cellular phone:
Cellular email:

10. Have you ever participated in Omotesando College and/or ewoman seminars?

　Yes
　No

11. Are you a registered "ewoman peer"?

　Yes
　No

12. Are you a registered "student of Omotesando College"?

　Yes
　No

13. Reason for and/or expectation of your participation in this seminar

* Upon receipt of your application, the confirmation notice will be sent by email. If you do not receive it within 30 minutes,

　please notify us by email at
　omokare.open@ewoman.co.jp
　Tel: 03-5766-7800

We look forward to seeing you at Omotesando College!