PRESENTATION　CERTIFICATION　REQUEST　FORM

Date(y/m/d):          /        /       

To:
The Chemical Society of Japan
1-5, Kanda-Surugadai, Chiyoda-ku,
Tokyo 101-8307, Japan
E-mail: info@chemistry.or.jp
Phone: +81-3-3292-6161
Fax: +81-3-3292-6318

From:
Name:	 					  
Affiliation:					  
						  
Address:					　
					　	　
E-mail:					 	　
Phone:						　
I request your certification that the following presentation has been made.
Event title: 										 
Organizer: 										 
Date and time: 										 
Place: 											 
Title and Number of Presentation: 							 
Author(s): 										 
Reason for the request: 									 
(Signature by Confirmer)
I hereby confirmed that the presentation was made with the above contents.
Date(y/m/d):          /        /       
Name:						 					
Affiliation:										
Address:										
  											
Phone:											

We hereby certify that the above information is true.
Shin-ichi Suzuki					　　　Date(y/m/d):          /        /       
Secretary-general
The Chemical Society of Japan