Automatic Withdrawal

Thank you for considering a gift to ICU.

Please send us the filled form, if you prefer monthly or yearly gift through automatic withdrawal from your bank account. Application forms will be sent to the designated address.


Last Name
First Name
Honorific
Address
e.g. 475 Riverside Drive,
   Suite 439, New York, NY 10115
Phone no.
e.g. +81-422-33-3041
E-mail
e.g. foi@icu.ac.jp
You are A/AN
*multiple answers allowed
FOI No./ Student ID No./ Graduated year/ RID & club n.(Rotarian)
e.g. F123456、s123456、c012345z、2001、
   RID2750, Tokyo Mitaka Club
Donation to be used for
Please see "Overview" for detailed information of aims and purposes.
Check here if you would like your donation to be anonymous.
Comment
Please indicate the group's name here,
for donation to PBS or Artificial Turf.