Application for Fukushima Medical University Support Donations

Date: Month/Day/Year

Name of individual or organization

Address 
Telephone 
Fax　　　　　

I hereby pledge funds to Fukushima Medical University:

1  Amount           　                                      (Yen)

2  Purpose         Fukushima Medical University Support

3  Public announcement authorization
□Donor name and amount of donation
□Donor name only
□Amount of donation
□No public disclosure

Within the limits of your authorization above, we would like to publish your name and/or donation amount in public relations magazines and online. Check the appropriate box above so we can comply with your wishes.
We will send a certificate for tax purposes to the name and address above.