Donation Application Input Screen

  1. Step 1 Input Donation Information
  2. Steps 2 Confirm Information
  3. Steps 3 Donation Completed

Donation Information

I want the donation to be used (to):*
Support*
I want the donation to be used (to):(その他)
Donation amount*
  • (JPY)

*Please apply for donation by credit card for 1,000 yen or more.

*If the amount of donation is less than 1,000 yen, please remit from a financial institution.

*If you have any questions, please contact us.(Contact information)

Donor Information

Applicant classification
Name*
First name
Last name    
Corporate name*    
Representative position*    
Representative name*    
Department in charge*    
Person in charge name*    
Address*
Address1
Address2
City, ZIP/Postal Code, Country
Telephone number*
E-mail address*
E-mail address (confirmation)*
Relationship with the corporation*
List of donors' names*

Your name will be posted in the list of donors in ESH’s newsletter or other publications.
Please select "Accept" if you approve of posting.
Please choose "Decline" if you do not want to post.

   
Information from Elizabeth Saunders Home*

Do you want to receive information from Elizabeth Sanders Home?

   
Public message
You can write a message within 140 characters.
Number of characters inputted: character

Comment
Please feel free to write a comment of up to 1000 characters.
Number of characters inputted: character

Payment Information

  • Payment by Credit Card

Payment can be made with any credit card displaying one of the following marks

visa master mufg dc ufj nicos jcb amex diners


● Credit Card number

  • *012345678999999

● Expiry date

/  Month / Year  * 01 / 25

* Enter only the last two digits of the year

* Please be sure to enter the expiry date in the order of month and year as shown on the card.

● CVV

*123

In order to prevent unauthorized use of your credit card, please input the CVV number as set out in the example below.

security_1 security_2 security_3

Payment InstructionsPayment Instructions



Once you have entered the required information and read the Information for donors, please click the "input confirmation" button.