Sunrise Japan Hospital Phnom Penh

Kind of membership course※

Gold membership

【Annual Fee ＄320/Registration Fee Free until September from October Registration Fee is ＄10】

Silver membership

【Annual Fee ＄120/Registration Fee Free until September from October Registration Fee is ＄10】

Bronze membership

【Annual Fee Free until June, From July ＄10/Registration Fee Free until September from October Annual Fee and Registration Fee is ＄10】

Family name※

Given name※

Sex※

Male Female

Date of Birth

Year Month Day

Age※

Years

Address※

Phone Number ※

E-mail Address※

Nationality※

Cambodia Other

National ID※

Emergency Contact Number※

Native Language※

Khmer English Japanese Chinese Other

Second Language※

Khmer English Japanese Chinese Other

Occupation※

Student Employee Own Business Other

Name of Work Place or School※

Kind of membership course※	Gold membership 【Annual Fee ＄320/Registration Fee Free until September from October Registration Fee is ＄10】 Silver membership 【Annual Fee ＄120/Registration Fee Free until September from October Registration Fee is ＄10】 Bronze membership 【Annual Fee Free until June, From July ＄10/Registration Fee Free until September from October Annual Fee and Registration Fee is ＄10】
Family name※
Given name※
Sex※	Male Female
Date of Birth	Year Month Day
Age※	Years
Address※
Phone Number ※
E-mail Address※
Nationality※	Cambodia Other
National ID※
Emergency Contact Number※
Native Language※	Khmer English Japanese Chinese Other
Second Language※	Khmer English Japanese Chinese Other
Occupation※	Student Employee Own Business Other
Name of Work Place or School※