Registration (Group Donation)

Corporation/Organization  
Department  
Name  

Country

  
Address  
City  
State  
ZIP  
E-mail  
Payment

By PayPal--- Minimum: $1 Maximum: $10,000

 
Bank Transfer Date
 

Amount　  (USD)

e.g.:100

 required

required in Bank Transfer only  

Note: Please make sure that your mail account accepts emails from @uls-donation.jp