New enrollment form

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Full nameFamilly nameGiven name
furiganaFamilly nameGiven name
Zip/Postal Code 392-0017
Province
city 諏訪市城南
numbers 1-2562-1
building name あさやけビル3階
Phone number 1000-10-1000
FAX number 1000-10-1000
*e-mail adress
*E-mail address (for verification)
*password
*Password (confirm)