New enrollment form

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*e-mail adress
*E-mail address (for verification)
*Password (confirm)
Full nameFamilly nameGiven name
furiganaFamilly nameGiven name
Zip/Postal Code 100-1000
city Kitakami Yokohama
numbers 3-24-555
building name tuhanbuild 4F
Phone number 1000-10-1000
FAX number 1000-10-1000