| GENERAL INFORMATION REQUIRED FOR MEMBERSHIP | |
| FAMILY NAME | |
| GIVEN NAMES | |
| MR/MRS/MS | |
| DATE OF BIRTH | |
| GENDER | |
| NATIVE LANGUAGE | |
| SECOND LANGUAGE | |
| THIRD LANGUAGE | |
| HOME ADDRESS | |
| TELEPHONE NUMBER | |
| MOBILE NUMBER | |
| EMAIL ADDRESS | |
| OCCUPATION | |
| POSITION IN OCCUPATION | |
| PREVIOUS EXPERIENCE IN TEA ACTIVITIES | |
| SCHOOL OF TEA | |
| URASENKE/OMOTOSENKE/OTHER | |
| PLACE OF STUDIES | |
| MEMBER OF URSASENKE | YES: |
| TANKOKAI | NO: |
| CERTIFICATE LEVEL | |
| TEACHER’S NAME | |
| TEACHER’S LOCAL | |
| TEA NAME IF HAVE ONE | |