| 氏名（姓）* | [text* sei-name] | 氏名（名）* | [text* na-name] |
|---|---|---|---|
| 氏名（姓）フリガナ* | [text* sei-name-furigana] | 氏名（名）フリガナ* | [text* na-name-furigana] |
| 生年月日* | [select year include_blank “1920” “1921” “1922” “1923” “1924” “1925” “1926” “1927” “1928” “1929” “1930” “1931” “1932” “1933” “1934” “1935” “1936” “1937” “1938” “1939” “1940” “1941” “1942” “1943” “1944” “1945” “1946” “1947” “1948” “1949” “1950” “1951” “1952” “1953” “1954” “1955” “1956” “1957” “1958” “1959” “1960” “1961” “1962” “1963” “1964” “1965” “1966” “1967” “1968” “1969” “1970” “1971” “1972” “1973” “1974” “1975” “1976” “1977” “1978” “1979” “1980” “1981” “1982” “1983” “1984” “1985” “1986” “1987” “1988” “1989” “1990” “1991” “1992” “1993” “1994” “1995” “1996” “1997” “1998” “1999” “2000” “2001” “2002” “2003” “2004” “2005” “2006” “2007” “2008” “2009” “2010” “2011” “2012” “2013” “2014”]年 | [select* month include_blank “1” “2” “3” “4” “5” “6” “7” “8” “9” “10” “11” “12”]月 | [select* day include_blank “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”]日 |
| 性別 | [radio seibetsu “男性” “女性”] | ||
| 郵便番号* | [text* zip-code] | ||
| ご住所* | [text* address] | ||
| 電話番号 | [text tel] | ||
| メールアドレス | [text e-mail] | ||
| ご勤務先名 | [text work] | ||
| ご勤務先名フリガナ | [text work-furigana] | ||
| 業種 | [select menu-biz “デザイン ” “マスコミ” “商社” “小売業” “製造業” “印刷業” “農林・水産業” “建設業” “通信・運輸” “メンテナンス” “医療機関” “コンピューター関連” “金融・不動産” “タレント” “スポーツ選手 ” “作家・芸術家 ” “公務員” “教育関連” “サービス業” “自由業” “パート・アルバイト” “専業主婦・主夫” “フリーター” “無職” “学生 ” “その他”] | ||
| 入会理由 | [textarea nyukairiyu] | ||
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