Japan-America Society of Indiana
“Japan Earthquake Relief Fund”
Donation Form
Please be sure to enclose your check or include credit card information below.
All contributions are tax-deductible to the extent allowable by law. For more information, call the Japan-America Society of Indiana office at 317-635-0123 or email . If you would like your name to be included on the donor list and / or receive an acknowledgement for tax purposes, kindly provide your contact information below.
DONOR INFORMATION (寄付者の情報)
Name: ______
Address: ______City:______State:_____ Zip: ______
Company:＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
E-Mail Address: ______Phone Number: ______
□ I wish to remain anonymous. （匿名での寄付を希望します）
PLEASE INDICATE DONATION INFORMATION (寄付方法についてご記述ください)
Enclosed is my donation by: □ cash （現金） □ check (小切手) □ credit card (□Visa / □ MC / □Amex)
(Please make checks payable to Japan Earthquake Relief Fund)
Enclosed Amount : $______
Credit Card Account No. ______Exp. Date ______
Billing Address (if not same above): ______
Japan-America Society of Indiana
“Japan Earthquake Relief Fund”
Donation Form
Please be sure to enclose your check or include credit card information below.
All contributions are tax-deductible to the extent allowable by law. For more information, call the Japan-America Society of Indiana office at 317-635-0123 or email . If you would like your name to be included on the donor list and / or receive an acknowledgement for tax purposes, kindly provide your contact information below.
DONOR INFORMATION (寄付者の情報)
Name: ______
Address: ______City:______State:_____ Zip: ______
Company:＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
E-Mail Address: ______Phone Number: ______
□ I wish to remain anonymous. （匿名での寄付を希望します）
PLEASE INDICATE DONATION INFORMATION (寄付方法についてご記述ください)
Enclosed is my donation by: □ cash （現金） □ check (小切手) □ credit card (□Visa / □ MC / □Amex)
(Please make checks payable to Japan Earthquake Relief Fund)
Enclosed Amount : $______
Credit Card Account No. ______Exp. Date ______
Billing Address (if not same above): ______