致习近平主席的公开信签字 (美洲组)
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姓名 *
(请用中文姓名填写)
出生日 *
MM
/
DD
/
YYYY
现居住地: 国家,州(省),市(郡,镇) *
(请用中文或英文填写)
原国内所在单位,职称 *
出国年,月 *
( 例: 1988,3 )
电话
( 例:001-609-711-1310 )
电子邮箱 *
签字 *
Required
是否同意公开签字者姓名 *
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