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					                                            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 admin@japanindiana.org. 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 admin@japanindiana.org. 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): ________________________________________________________________

				
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