Donation Request Form

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

Donation Information

※This mark indicates required fields
Purpose of Donation※
Donation Destination※
寄付目的（その他）
Donation Type and Amount※

Select one of the donation methods below and input the donation amount

  • (JPY)
  • (JPY)
  • (JPY)
  • (JPY)

Only for those who have already registered online. You can apply without logging in. (Excluding continuing donations)
Once registered online, you do not need to enter your application information each time.
For those already registered: enter your login ID and password, and click the "login" button. (Your registered information will be reflected in the application form).
For those not yet registered: leave this blank and proceed to the following item. You may register online at the end of the process.

オンライン登録のご案内 Online Registration Information

Login ID
Password

Forgot Your Password?

Donor Information

Donor classification
Name※  
Organization name※    
Title of representative※    
Name of representative※    
Division of contact person※    
Name of contact person※    
Date of Birth※  /  /  
Gender    
Mailing Address※
Block number Any
City/ State/ ZIP
Country
Daytime Phone Number※
Email address※

You will receive an email to notify you that your application has been completed from the following email address: kikin@office.hiroshima-u.ac.jp. Depending on your spam settings, you may not receive the email.

Email address (confirmation)※
Your relationship with Hiroshima University※
（Multiple selection possible）




【 Alumni/Master's student 】
Year of Graduation　　　　　　　　　　　　　　　 ：
Department/Research Field　　　　　　　　　Any：
【 Family member of Alumni/Master's student 】
Family member of Alumni/Master's student　　　 ：
Year of Graduation　　　　　　　　　　　　　　　 ：
Department/Research Field　　　　　　　　　Any：
【 Parents of a current student 】
Name of the Student　　　　　　　　　　　　　　 ：
Year of Enrollment of the Student　　　　　　　　 ：
Department/Research Field of Current studentAny：
【 Current student 】
Year of Enrollment of the Student　　　　　　　　 ：
Department/Research Field of Current studentAny：
【 Faculty/Staff 】
Department　　　　　　　　　　　　　　　　　Any：
Position　　　　　　　　　　　　　　　　　　　Any：
【 Former Faculty/Staff 】
Department　　　　　　　　　　　　　　　　　Any：
Position　　　　　　　　　　　　　　　　　　　Any：
【 General 】
General　　　　　　　　　　　　　　　　　　　Any：
Introducing donors in public relations magazines and websites※

   
Comment on Our Website
We will post the message on our website.
Please feel free to write a comment up to 140 characters.
Amount of characters: characters
Advice and proposal
Please feel free to write a comment up to 1000 characters. Amount of characters: characters

Payment details

  • Credit card payment

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

visa master jcb amex diners


● Credit Card number

  • * 012345678999999

● Expiry date

/  month / year * 01/25

Input only the last two digits of the year

Enter the expiration date in the order of "month / year" as shown on the card.

● CVV number

* 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

決済方法のご説明Description of the settlement method

Need a New Account?


  • When you create an account, you can skip entering the application information from the next time.


Once you have entered the required information and read the application notes,
please click the "Next" button.