{"id":11089,"date":"2019-10-07T21:00:56","date_gmt":"2019-10-07T21:00:56","guid":{"rendered":"https:\/\/www.usjapancouncil.org\/?page_id=11089"},"modified":"2025-11-18T05:27:20","modified_gmt":"2025-11-18T05:27:20","slug":"usjc-membership-nomination-form","status":"publish","type":"page","link":"https:\/\/www.usjapancouncil.org\/ja\/usjc-membership-nomination-form\/","title":{"rendered":"USJC Membership: Nomination Form"},"content":{"rendered":"\n<p>The U.S.-Japan Council comprises of Council Leaders, Associates, and supporters committed to the mission of the organization. Included in these ranks are top leaders from major corporations, academia and research, politics and law, as well as entrepreneurs, small business owners and thought leaders.<\/p>\n\n\n\n<p>We encourage our current USJC leaders to help us grow our network by nominating potential USJC members.<\/p>\n\n\n\n<p>Please complete the form below. Thank you for your nomination.<\/p>\n\n\n\n<p>Please click <a href=\"https:\/\/www.dropbox.com\/scl\/fi\/wf2pjsem3asutev0s71gm\/Membership-Regions-Map.pdf?rlkey=gqplfelz29sap6k2yggzmv38r&amp;st=42kze39g&amp;dl=0\">here<\/a> to see which states are included in each region.<\/p>\n\n\n\n<p><em>Please note that this form must be completed in one sitting, as information that you input cannot be saved until the form is submitted.<\/em><\/p>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f17548-o1\" lang=\"ja\" dir=\"ltr\" data-wpcf7-id=\"17548\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ja\/wp-json\/wp\/v2\/pages\/11089#wpcf7-f17548-o1\" method=\"post\" class=\"wpcf7-form init o-form chimpmatic-1.7.3 25a0c1e5bd85 cmatic-conn cmatic-aud-5 cmatic-mapd0-0 cmatic-v0976 cmatic-pro-v173 cmatic-sent-0 cmatic-total-0\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"17548\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ja\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f17548-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:17548,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;nominator-region-other&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominator-region&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;nominee-title-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-title&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;nominee-region-other&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-region&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;nominee-field-other&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-field-occupation&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Other&quot;}]},{&quot;then_field&quot;:&quot;nominee-role-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-suggested-role&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Associate (Ages 18 - 39)&quot;}]},{&quot;then_field&quot;:&quot;nominee-bio-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-linkedin&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;N\\\/A&quot;}]},{&quot;then_field&quot;:&quot;nominee-bio-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-linkedin&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;n\\\/a&quot;}]},{&quot;then_field&quot;:&quot;nominee-bio-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-linkedin&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;NA&quot;}]},{&quot;then_field&quot;:&quot;nominee-bio-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;nominee-linkedin&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;na&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<\/fieldset>\n<h4>\u7533\u8fbc\u8005\u306e\u540d\u524d\n<\/h4>\n<p><label>\u540d<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span> <\/label>\n<\/p>\n<p><label>\u59d3<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span> <\/label>\n<\/p>\n<p><label>\u30e1\u30fc\u30eb\u30a2\u30c9\u30ec\u30b9<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominator-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"nominator-email\" \/><\/span><\/label>\n<\/p>\n<p><label>\u5730\u57df<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominator-region\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required a-form__select\" aria-required=\"true\" aria-invalid=\"false\" name=\"nominator-region\"><option value=\"\u5730\u57df\">\u5730\u57df<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Seattle\">Seattle<\/option><option value=\"Portland\">Portland<\/option><option value=\"Northern California\">Northern California<\/option><option value=\"Southern California\">Southern California<\/option><option value=\"Southwest\">Southwest<\/option><option value=\"Midwest\">Midwest<\/option><option value=\"Rocky Mountain\">Rocky Mountain<\/option><option value=\"Southeast\">Southeast<\/option><option value=\"Northeast\">Northeast<\/option><option value=\"New York\">New York<\/option><option value=\"Washington, D.C.\">Washington, D.C.<\/option><option value=\"Japan\">Japan<\/option><option value=\"\u305d\u306e\u4ed6\">\u305d\u306e\u4ed6<\/option><\/select><\/span>\n<\/p>\n<div data-id=\"nominator-region-other\" data-orig_data_id=\"nominator-region-other\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><label class=\"a-form__label\">\u5730\u57df<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominator-other-region\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominator-other-region\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<h4>\u63a8\u85a6\u3055\u308c\u308b\u4eba\u306e\u60c5\u5831\n<\/h4>\n<p>\u3042\u306a\u305f\u304c\u63a8\u85a6\u3059\u308b\u500b\u4eba\u306b\u3064\u3044\u3066\u3001\u4ee5\u4e0b\u306e\u60c5\u5831\u3092\u5165\u529b\u3057\u3066\u304f\u3060\u3055\u3044\u3002\n<\/p>\n<p><label>\u656c\u79f0<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-title\" \/><\/span>\n<\/p>\n<p><label>\u540d<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-first-name\" \/><\/span> <\/label>\n<\/p>\n<p><label>\u59d3<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-last-name\" \/><\/span> <\/label>\n<\/p>\n<div class=\"m-form__tooltip\">\n\t<div class=\"suggested_roles\">\n\t\t<div>\n\t\t\t<p><label class=\"a-form__label\">\u3075\u3055\u308f\u3057\u3044\u3068\u601d\u308f\u308c\u308b\u5f79\u5272\uff08\u30e1\u30f3\u30d0\u30fc\u306e\u7a2e\u5225\uff09 <span class=\"required\">*<\/span><span class=\"tooltip_trigger\"><img decoding=\"async\" src=\"\/wp-content\/uploads\/2019\/10\/question.svg\" alt=\"Open Modal Box\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t\t<div class=\"m-form__tip\">\n\t\t\t\t<p><strong>\u30ab\u30a6\u30f3\u30b7\u30eb\u30fb\u30ea\u30fc\u30c0\u30fc\u306f\u3001<\/strong>\u7c73\u65e5\u30ab\u30a6\u30f3\u30b7\u30eb\u306e\u30df\u30c3\u30b7\u30e7\u30f3\u3068\u30b4\u30fc\u30eb\u3092\u652f\u63f4\u3057\u3001\u6642\u9593\u3084\u5c02\u9580\u77e5\u8b58\u3001\u30ea\u30bd\u30fc\u30b9\u3092\u63d0\u4f9b\u3059\u308b\u3053\u3068\u306b\u3088\u3063\u3066\u3001\u30a2\u30e1\u30ea\u30ab\u4eba\u304a\u3088\u3073\u65e5\u672c\u4eba\u3092\u30d7\u30ed\u30b0\u30e9\u30e0\u3084\u6d3b\u52d5\u306b\u53c2\u52a0\u3055\u305b\u308b\u305f\u3081\u306b\u5c3d\u529b\u3059\u308b\u30ea\u30fc\u30c0\u30fc\u3067\u3059\u3002\n\t\t\t\t<\/p>\n\t\t\t\t<p><strong>\u30a2\u30bd\u30b7\u30a8\u30fc\u30c8\u306f<\/strong>\u3001USJC TOMODACHI \u30d7\u30ed\u30b0\u30e9\u30e0\u306e\u5352\u696d\u751f\u306e\u4e2d\u304b\u3089\u9078\u3070\u308c\u305f\u30e1\u30f3\u30d0\u30fc\u306e\u307b\u304b\u300118\u6b73\u304b\u308940\u6b73\u307e\u3067\u306e\u82e5\u3044\u6709\u8b58\u8005\u3067\u3059\u3002\n\t\t\t\t<\/p>\n\t\t\t\t<p><strong>\u30d5\u30ec\u30f3\u30ba\u30fb\u30aa\u30d6\u30fb\u30b6\u30fb\u30ab\u30a6\u30f3\u30b7\u30eb\u306f<\/strong>\u3001\u7c73\u65e5\u95a2\u4fc2\u3092\u69cb\u7bc9\u3059\u308b\u3046\u3048\u3067\u306e\u30ab\u30a6\u30f3\u30b7\u30eb\u306e\u30df\u30c3\u30b7\u30e7\u30f3\u3068\u76ee\u6a19\u3092\u652f\u63f4\u3059\u308b\u884c\u52d5\u3092\u8d77\u3053\u3059\u3001\u512a\u79c0\u306a\u30ea\u30fc\u30c0\u30fc\u3001\u5c02\u9580\u5bb6\u3001\u8ca2\u732e\u8005\u305f\u3061\u3067\u3059\u3002\u30d5\u30ec\u30f3\u30ba\u30fb\u30aa\u30d6\u30fb\u30b6\u30fb\u30ab\u30a6\u30f3\u30b7\u30eb\u306f\u3001\u5148\u7d04\u3084\u6642\u9593\u306e\u5236\u7d04\u3001\u4ed5\u4e8b\u306e\u4e8b\u60c5\u3001\u7a4d\u6975\u7684\u306a\u95a2\u4e0e\u306b\u5236\u9650\u304c\u3042\u308b\u306a\u3069\u306e\u7406\u7531\u3067\u30ab\u30a6\u30f3\u30b7\u30eb\u30fb\u30ea\u30fc\u30c0\u30fc\u3068\u3057\u3066\u306e\u53c2\u52a0\u306f\u3067\u304d\u306a\u304f\u3068\u3082\u3001\u30ab\u30a6\u30f3\u30b7\u30eb\u3092\u652f\u63f4\u3059\u308b\u3053\u3068\u304c\u3067\u304d\u307e\u3059\u3002\n\t\t\t\t<\/p>\n\t\t\t\t<p><button class=\"a-search__close-button\" aria-label=\"Close Nominee Role Information Modal\">\u00d7<\/button>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-suggested-role\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"nominee-suggested-role\" value=\"\u30ab\u30a6\u30f3\u30b7\u30eb\u30fb\u30ea\u30fc\u30c0\u30fc\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u30ab\u30a6\u30f3\u30b7\u30eb\u30fb\u30ea\u30fc\u30c0\u30fc<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"nominee-suggested-role\" value=\"\u30a2\u30bd\u30b7\u30a8\u30fc\u30c8 \uff0818-40\u6b73\uff09\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30bd\u30b7\u30a8\u30fc\u30c8 \uff0818-40\u6b73\uff09<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"nominee-suggested-role\" value=\"\u30d5\u30ec\u30f3\u30ba\u30fb\u30aa\u30d6\u30fb\u30b6\u30fb\u30ab\u30a6\u30f3\u30b7\u30eb\" \/><span class=\"wpcf7-list-item-label\">\u30d5\u30ec\u30f3\u30ba\u30fb\u30aa\u30d6\u30fb\u30b6\u30fb\u30ab\u30a6\u30f3\u30b7\u30eb<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"nominee-role-group\" data-orig_data_id=\"nominee-role-group\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><label class=\"a-form__label\">Date of Birth<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-birthday\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" placeholder=\"mm\/dd\/yyyy\" value=\"\" type=\"text\" name=\"nominee-birthday\" \/><\/span><br \/>\n<\/label>\n\t<\/p>\n<\/div>\n<p><label>\u5730\u57df<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-region\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required a-form__select\" aria-required=\"true\" aria-invalid=\"false\" name=\"nominee-region\"><option value=\"Choose Region\">Choose Region<\/option><option value=\"Hawaii\">Hawaii<\/option><option value=\"Seattle\">Seattle<\/option><option value=\"Portland\">Portland<\/option><option value=\"Northern California\">Northern California<\/option><option value=\"Southern California\">Southern California<\/option><option value=\"Southwest\">Southwest<\/option><option value=\"Midwest\">Midwest<\/option><option value=\"Rocky Mountain\">Rocky Mountain<\/option><option value=\"Southeast\">Southeast<\/option><option value=\"Northeast\">Northeast<\/option><option value=\"New York\">New York<\/option><option value=\"Washington, D.C.\">Washington, D.C.<\/option><option value=\"Japan\">Japan<\/option><option value=\"\u305d\u306e\u4ed6\">\u305d\u306e\u4ed6<\/option><\/select><\/span>\n<\/p>\n<div data-id=\"nominee-region-other\" data-orig_data_id=\"nominee-region-other\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><label class=\"a-form__label\">\u5730\u57df<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominator-other-region\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominator-other-region\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<p><label>\u8077\u696d<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-field-occupation\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required a-form__select\" aria-required=\"true\" aria-invalid=\"false\" name=\"nominee-field-occupation\"><option value=\"Choose Field\/Occupation\">Choose Field\/Occupation<\/option><option value=\"\u4f01\u696d\">\u4f01\u696d<\/option><option value=\"\u6559\u80b2\">\u6559\u80b2<\/option><option value=\"\u653f\u5e9c\">\u653f\u5e9c<\/option><option value=\"\u6cd5\u5f8b\">\u6cd5\u5f8b<\/option><option value=\"\u533b\u7642\uff0f\u4fdd\u5065\">\u533b\u7642\uff0f\u4fdd\u5065<\/option><option value=\"\u8ecd\u968a\">\u8ecd\u968a<\/option><option value=\"\u975e\u55b6\u5229\u56e3\u4f53\">\u975e\u55b6\u5229\u56e3\u4f53<\/option><option value=\"\u305d\u306e\u4ed6\">\u305d\u306e\u4ed6<\/option><\/select><\/span>\n<\/p>\n<div data-id=\"nominee-field-other\" data-orig_data_id=\"nominee-field-other\"  class=\"\" data-class=\"wpcf7cf_group\">\n\t<p><label class=\"a-form__label\">Specify Field<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-other-field\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-other-field\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<p><label> \u5f79\u8077\u540d<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-job-title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-job-title\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u52e4\u52d9\u5148<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-organization\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-organization\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u30e1\u30fc\u30eb\u30a2\u30c9\u30ec\u30b9<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"nominee-email\" \/><\/span> <\/label>\n<\/p>\n<h4> \u9001\u4ed8\u5148\u4f4f\u6240\n<\/h4>\n<p><label> \u4f4f\u6240 1<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-address-street\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-address-street\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u4f4f\u6240 2<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-address-street-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-address-street-2\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u5e02<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-address-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-address-city\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u5dde\u307e\u305f\u306f\u5730\u57df<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-address-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-address-state\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u90f5\u4fbf\u756a\u53f7<span class=\"required\">*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-address-zip-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nominee-address-zip-code\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u56fd<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address-country\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required a-form__select\" aria-required=\"true\" aria-invalid=\"false\" name=\"address-country\"><option value=\"Choose Country\">Choose Country<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"\u00c5land Islands\">\u00c5land Islands<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Anguilla\">Anguilla<\/option><option value=\"Antarctica\">Antarctica<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Aruba\">Aruba<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bermuda\">Bermuda<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia (Plurinational State of)\">Bolivia (Plurinational State of)<\/option><option value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Bouvet Island\">Bouvet Island<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option value=\"Brunei Darussalam\">Brunei Darussalam<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cabo Verde\">Cabo Verde<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cayman Islands\">Cayman Islands<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Christmas Island\">Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo\">Congo<\/option><option value=\"Congo, Democratic Republic of the\">Congo, Democratic Republic of the<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cura\u00e7ao\">Cura\u00e7ao<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czechia\">Czechia<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Eswatini\">Eswatini<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"French Guiana\">French Guiana<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"French Southern Territories\">French Southern Territories<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia\">Gambia<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Gibraltar\">Gibraltar<\/option><option value=\"Greece\">Greece<\/option><option value=\"Greenland\">Greenland<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guadeloupe\">Guadeloupe<\/option><option value=\"Guam\">Guam<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guernsey\">Guernsey<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Heard Island and McDonald Islands\">Heard Island and McDonald Islands<\/option><option value=\"Holy See\">Holy See<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hong Kong\">Hong Kong<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran (Islamic Republic of)\">Iran (Islamic Republic of)<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jersey\">Jersey<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea (Democratic People&#039;s Republic of)\">Korea (Democratic People&#039;s Republic of)<\/option><option value=\"Korea, Republic of\">Korea, Republic of<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\">Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macao\">Macao<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Martinique\">Martinique<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mayotte\">Mayotte<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia (Federated States of)\">Micronesia (Federated States of)<\/option><option value=\"Moldova, Republic of\">Moldova, Republic of<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Montserrat\">Montserrat<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Caledonia\">New Caledonia<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"North Macedonia\">North Macedonia<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Palestine, State of\">Palestine, State of<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Pitcairn\">Pitcairn<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"R\u00e9union\">R\u00e9union<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russian Federation\">Russian Federation<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Barth\u00e9lemy\">Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\">Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Martin (French part)\">Saint Martin (French part)<\/option><option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Sint Maarten (Dutch part)\">Sint Maarten (Dutch part)<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Georgia and the South Sandwich Islands\">South Georgia and the South Sandwich Islands<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Svalbard and Jan Mayen\">Svalbard and Jan Mayen<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syrian Arab Republic\">Syrian Arab Republic<\/option><option value=\"Taiwan, Province of China\">Taiwan, Province of China<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania, United Republic of\">Tanzania, United Republic of<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\">United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"United States Minor Outlying Islands\">United States Minor Outlying Islands<\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Venezuela (Bolivarian Republic of)\">Venezuela (Bolivarian Republic of)<\/option><option value=\"Viet Nam\">Viet Nam<\/option><option value=\"Virgin Islands (British)\">Virgin Islands (British)<\/option><option value=\"Virgin Islands (U.S.)\">Virgin Islands (U.S.)<\/option><option value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/span>\n<\/p>\n<p><label> \u3053\u306e\u4f4f\u6240\u306f:<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-address-type\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"nominee-address-type\" value=\"Work address\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Work address<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"nominee-address-type\" value=\"Home address\" \/><span class=\"wpcf7-list-item-label\">Home address<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"nominee-address-type\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> \u96fb\u8a71\u756a\u53f7<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-phone-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel a-form__input\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"nominee-phone-number\" \/><\/span> <\/label>\n<\/p>\n<p><label>\u3053\u306e\u4eba\u7269\u3092\u63a8\u85a6\u3059\u308b\u7406\u7531\u3092\u8ff0\u3079\u3066\u304f\u3060\u3055\u3044\u3002<span class=\"required\">*<\/span><br \/>\n<span class=\"sublabel\">\uff08\u80cc\u666f\u3001\u7d4c\u9a13\u3001\u8077\u696d\u3001\u5730\u57df\u6d3b\u52d5\u3001\u53d7\u8cde\u6b74\u306a\u3069\uff09<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-consideration\"><textarea cols=\"60\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" name=\"nominee-consideration\"><\/textarea><\/span><br \/>\n<\/label>\n<\/p>\n<p><label>\u3053\u306e\u4eba\u7269\u3068\u306e\u95a2\u4fc2\u30fb\u7d9a\u67c4\u3092\u6559\u3048\u3066\u304f\u3060\u3055\u3044\u3002<span class=\"required\">*<\/span><br \/>\n<span class=\"sublabel\">\uff08\u540c\u50da\u3001\u53cb\u4eba\u3001\u5730\u57df\u30e1\u30f3\u30d0\u30fc\u306a\u3069\uff09<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-relation\"><textarea cols=\"60\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required a-form__input\" aria-required=\"true\" aria-invalid=\"false\" name=\"nominee-relation\"><\/textarea><\/span><br \/>\n<\/label>\n<\/p>\n<h4>\u7167\u4f1a\u5148\u306e\u60c5\u5831\n<\/h4>\n<p>\u30ab\u30a6\u30f3\u30b7\u30eb\u306e\u30df\u30c3\u30b7\u30e7\u30f3\u3092\u652f\u63f4\u3059\u308b\u305f\u3081\u306b\u9069\u3057\u305f\u4eba\u7269\u3092\u30ab\u30a6\u30f3\u30b7\u30eb\u3078\u8fce\u3048\u308b\u3079\u304f\u3001\u63a8\u85a6\u3055\u308c\u305f\u500b\u4eba\u306b\u3064\u3044\u3066\u306e\u7167\u4f1a\u5148\u3068\u3057\u3066\u3001\u3042\u306a\u305f\u4ee5\u5916\u3067\u3053\u306e\u4eba\u7269\u3092\u77e5\u308bUSJC\u30e1\u30f3\u30d0\u30fc\u3092\u304a\u77e5\u3089\u305b\u304f\u3060\u3055\u3044\u3002\n<\/p>\n<p>\u5c11\u306a\u304f\u3068\u3082\u4e00\u4eba\u306e\u7167\u4f1a\u5148\u3092\u4e0b\u8a18\u306b\u5165\u529b\u3057\u3066\u304f\u3060\u3055\u3044\u3002\n<\/p>\n<p><label>\u4ee5\u4e0b\u306b\u6319\u3052\u308bUSJC\u30e1\u30f3\u30d0\u30fc\u306f\u3001\u3042\u306a\u305f\u304c\u63a8\u85a6\u3059\u308b\u4eba\u7269\u3092\u77e5\u3063\u3066\u304a\u308a\u3001\u540c\u69d8\u306b\u3053\u306e\u4eba\u7269\u3092\u30e1\u30f3\u30d0\u30fc\u306b\u63a8\u85a6\u3059\u308b\u610f\u601d\u304c\u3042\u308b\u3053\u3068\u3092\u78ba\u8a8d\u3057\u3066\u3044\u307e\u3059\u304b\u3002<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-membership-connection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"nominee-membership-connection\" value=\"\u306f\u3044\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"nominee-membership-connection\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff11\uff1a\u540d<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-1-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-1-first-name\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff11\uff1a\u59d3<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-1-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-1-last-name\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff11\uff1a\u30e1\u30fc\u30eb\u30a2\u30c9\u30ec\u30b9<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-1-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-1-email\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff12\uff1a\u540d<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-2-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-2-first-name\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff12\uff1a\u59d3<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-2-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-2-last-name\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff12\uff1a\u30e1\u30fc\u30eb\u30a2\u30c9\u30ec\u30b9<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-2-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-2-email\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff13\uff1a\u540d<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-3-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-3-first-name\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff13\uff1a\u59d3<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-3-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-3-last-name\" \/><\/span>\n<\/p>\n<p><label> \u7167\u4f1a\u5148\uff13\uff1a\u30e1\u30fc\u30eb\u30a2\u30c9\u30ec\u30b9<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reference-3-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text a-form__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"reference-3-email\" \/><\/span>\n<\/p>\n<h4>\u63a8\u85a6\u3055\u308c\u308b\u500b\u4eba\u306e\u4eba\u7269\u7d39\u4ecb\n<\/h4>\n<p>\u3042\u306a\u305f\u304c\u63a8\u85a6\u3059\u308b\u4eba\u7269\u306e\u7565\u6b74\u3092\u63d0\u51fa\u3057\u3066\u304f\u3060\u3055\u3044\u3002\uff08\u82f1\u6587\u3067150-200\u8a9e\u4ee5\u5185\uff09 \u3053\u306e\u30d5\u30a9\u30fc\u30e0\u306b\u6dfb\u4ed8\u3059\u308b\u304b\u3001Merissa Nakamura\uff08<a href=\"mailto:mnakamura@usjapancouncil.org\">mnakamura@usjapancouncil.org<\/a>\uff09\u3042\u3066\u306b\u30e1\u30fc\u30eb\u3067\u9001\u4fe1\u3057\u3066\u304f\u3060\u3055\u3044\u3002 \u4f01\u696d\u30a6\u30a7\u30d6\u30b5\u30a4\u30c8\u306b\u63b2\u8f09\u3055\u308c\u3066\u3044\u308b\u7565\u6b74\u3067\u3082\u69cb\u3044\u307e\u305b\u3093\u3002\n<\/p>\n<p><label>\u30d5\u30a1\u30a4\u30eb\u306e\u6dfb\u4ed8<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nominee-biography\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"nominee-biography\" \/><\/span>\n<\/p>\n<p><label> \u79c1\u306f\u3001\u4e0a\u306b\u8a18\u8f09\u3055\u308c\u305f\u5185\u5bb9\u304c\u78ba\u304b\u306b\u771f\u5b9f\u3067\u3042\u308a\u6b63\u78ba\u3067\u3042\u308b\u3053\u3068\u3092\u3053\u3053\u306b\u8a93\u3044\u307e\u3059\u3002 \u79c1\u306f\u30b9\u30dd\u30f3\u30b5\u30fc\u306b\u306a\u308b\u3053\u3068\u306b\u3088\u3063\u3066\u3001\u3053\u306e\u4eba\u7269\u304c\u78ba\u304b\u306bUSJC\u30b3\u30df\u30e5\u30cb\u30c6\u30a3\u306b\u643a\u308f\u308b\u3088\u3046\u8cac\u4efb\u3092\u8ca0\u3046\u3053\u3068\u3092\u627f\u77e5\u3057\u307e\u3059\u3002<span class=\"required\">*<\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nomination-accuracy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"nomination-accuracy\" 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