Donation Form
Date: MM / DD
Amount of donation:
/ YYYY
JPY
*Please arrange your donation in Japanese yen.
Name
First name
Middle name
Last name
Ms./Mrs./Miss./Mr./Dr.
Address
Postcode:
Phone number
Country:
（Country code:
）-
E-mail address
JFCR lists the names of donors on the bulletin board at the outpatient floor for one year, and on official website. For
individuals who donate ¥100,000 or more, JFCR creates the donor’s nameplates to honor them and displays plates at the
outpatient floor of the hospital. If you do not want your name shown on the donor’s list, please check below.
❏ I prefer to make my donation anonymously.
Message (if any)
3-8-31 Ariake, Koto-ku, Tokyo 135-8550 JAPAN
TEL: +81-3-3570-0401
FAX: +81-3-3520-0141
E-mail: kikaku@ml.jfcr.or.jp