STEP1 Entry
Japanese

Donation Information

*Please note that all fields followed by an asterisk must be filled in.

 Type of donation Asahikawa Medical University Fund(Please choose one in the following pulldown menu.)
 Purpose of donation
Payment method
Amount of donation  yen   

Subscription Information

*Please note that all fields followed by an asterisk must be filled in.

Individual / Corporation
Name First name      Last name    
Sex
Date of birth year   month   day  
Company name
 Name of representative First name      Last name    
Name of the person in charge First name      Last name    
E-mail address
 of the person in charge

Please enter again to reconfirm.

Address
City/State/ZIP
Country
 Phone number  (Do not include hyphens.)
E-mail address

Please type it again to reconfirm.

Relationship to university
 Student id number
 Student name
 Department
    Student grade year
 The year of graduation year
 Belonging
 General

Credit Card Information

*Please note that all fields followed by an asterisk must be filled in.

Credit card number  (Do not include hyphens.)
Valid through month   year  
Security code  Security code: three or four digit number printed on the backside of your credit card.

Questionnaire

(1) How You Would Like Your Donation to Be Spent If you chose "(4) Other" in "Purpose of donation" above, please let us know about why you decided to donate.
( 300 characters or less. )
(2) Inscription of Your Name on the Plaque Would you like your name to be inscribed on the Donor Recognition Plaque? If an individual donates 100,000 yen or higher, or a corporation donates 500,000 yen or higher, you will be given a title of Donation Member and your name will be inscribed on the plaque.

( 300 characters or less. )
(3) Inclusion of Your Name in the Donation List Record Would you like your name to be included in the Donation List Record?
( 300 characters or less. )
      The university of bokin entrust business Sakura Information Systems Co., Ltd.