Application Form ○○○○All blanks must be completed date: To the President of Hiroshima University Ochi Mitsuo



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növüApplication form

Disaster Relief Donation for the Indonesian Earthquake

Application Form



○○○○All blanks must be completed


DATE:         


To the President of Hiroshima University

Ochi Mitsuo



Faculty / Department

____________________________________________________________

Name ______________________________________________________

Contact ( Tel or E-mail) _________________________________________


Donation Amount              JPY

……………………………………………………………………………………………………

Receipt
DATE:         




To                     


This is to acknowledge that we received




            JPY
as a relief donation for the Indonesian earthquake.

President, Hiroshima University  Ochi Mitsuo



Official seal of President,

Hirosima University

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