Donation Request Form

Step 1 Entry
Step 2 Confirmation
Step 3 Completion

Donation Information

Donation Purpose※
Donation Purpose (please specify)※
Donation Purpose(please specify)※	Education Support Projects
Donation Purpose(Other)
Donation Method and Amount※	Please select. One-Time Donation (JPY) Monthly Donation (JPY) Biannual Donation (JPY) Annual Donation (JPY)

Personal Information

Application Category
Name※	Last Name First Name
Organization name※
Business Title of Representative※
Name of representative※
Division of Contact Person※
Name of contact person※
Date of Birth
Address※	Address1 Address2 City/ State/ ZIP
Telephone number ※
E-mail Address※
E-mail Address (confirmation)※
E-newsletter※	Accept I do not accept

Your relationship with Gifu University※	Year of Graduation　　　　　： Faculty/Graduate School： Year　　　　　　： Faculty/Graduate School： Student Name　　　　　　： Student ID Number： Year　　　　　　： Faculty/Graduate School　　　： Department： Department：

Listing of Donors' Name※	We may post your name and the amount of donation on our website. Please place a check mark in the box below to indicate your agreement/disagreement with the posting. Agree with the posting Do not agree with the posting of my name and amount of donation Do not agree with the posting of my amount of donation
Display of Nameplate※	We may display your nameplate as a donor (who have donated an accumulated total of 100,000 yen or more for an individual, and an accumulated total of 500,000 yen or more for a cooperation/organization) Agree with the display Do not agree with the display
Message to Gifu University	You can write a brief comment on our website. Please enter any comments or questions (within 140 characters) Number of characters: characters I wish my name to be published on the website. 　新規お申込の方は、ご加入のきっかけをご記入いただけましたら幸いです
Advice and Proposal	Please enter any comments or questions (within 1,000 characters). Number of characters: characters

Payment Information

Payment by Credit Card

Use previous credit card

● Credit Card Number :

● Card Expiry Date :

Use a new credit card

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

visa

master

mufg

ufj

nicos

jcb

amex

diners

Change your credit card information

Credit Card number

e.g.) 012345678999999

Card Expiry Date

/ e.g.) 01/25

*Enter only the last two digits of the year.

*Please be sure to input the month then the year.

Card Verification Code

e.g.) 123

In order to prevent unauthorized use of your credit card, please follow the example below.

security_eng_1

security_eng_2

security_eng_3

I will use this card next time, too. (Please create a new account below.)

How to Make A Donation by Credit Card

New Account

Create a New Account
Please use this option if you would like your information to be saved for the next time you apply.

Please read the Notices before submitting this form.